| Objectives:Age-related macular degeneration(AMD)is an age-related blinding degenerative retinal disease.In recent years,nutritional intervention has emerged as a simple and cost-effective strategy to ameliorate the risk of developing AMD.However,existing nutritional interventions for AMD do not have standardized guidelines and guidance,and lack a targeted,systematic,and holistic management model,resulting in unsatisfactory intervention outcomes.Therefore,based on a full understanding of the nutritional status and nutritional management needs of AMD patients,combined with the results of evidence integration of AMD nutritional management,this study aims to construct a holistic nutritional management plan for AMD patients based on mobile medical applications,in order to improve patient intervention compliance,further improve prognosis,and improve patient quality of life.Meanwhile,it is also considered to effectively reduce the cost of disease management and improve the utilization of medical resources.Methods:1.Research on the current dietary nutrition status and nutritional mangement needs of AMD patientsFirst,a convenient sample of 215 AMD patients were investigated by questionnaire survey,and the dietary intake,nutritional structure and nutritional status of the patients were evaluated;At the same time,a purposive and convenient sample of 24 AMD patients who visited the ophthalmology clinic were selected to take face-to-face semi-structured interviews to explore the influencing factors and needs of nutritional intervention of patients.The themes and subthemes were obtained based on the COM-B model and according to Colaizzi’s seven-step method.2.Integrating evidence of nutrition management for AMD patientsSearch domestic and foreign databases and the official websites of relevant associations for evidence on nutritional intervention for AMD patients were searched and summarized,including clinical guidelines,systematic reviews,evidence summaries,and original studies.The search time limit is from the establishment of the database to September 26,2021,and the quality evaluation and evidence integration of the included evidence will be conducted.3.Constructing a whole-course nutrition management plan for AMD patientsBased on the key information obtained from the integration of evidence-based evidence related to nutrition intervention for AMD in the early stage,combined with the results of nutritional status investigation,nutritional problems and needs,and the initial core indicators of AMD’s whole-course nutritional intervention program was formed.Experts in relevant fields were invited to revise the intervention plan.First,a total of 21 experts are selected to conduct preliminary review,evaluation and revision of all levels of indicators of the intervention plan through Delphi expert consultation.For the nutritional intervention plan,the overall design of the intervention plan,software function realization and feasibility were discussed and revised by the method of expert group working meeting.Finally,the final version of the AMD intelligent whole-process nutritional management program was determined.4.Designing and developing a whole-process nutrition management application for AMD patientsAccording to the needs of AMD patients’ m Health intervention and the specific construction plan based on the previous research results,the agile development model was applied.And the research and development and testing of i OS system,Android system and PC-side background data management system were carried out by researchers and technical personnel.After the development was completed,six patients were selected to test the functional use of the patient terminal.And at the same time,the background administrator conducted a test and inspection on the PC terminal,and then gave feedback and revision again to determine the final version of the AMD whole-process nutrition management application.5.Verifying preliminary the effectiveness of the whole-process nutrition management program for AMD patients based on m Health applicationsSeventy-two AMD patients were invited who met the inclusion criteria to verify the effectiveness of the whole-process nutrition management scheme based on mobile medical applications by a randomized controlled trial.The experimental group received mobile medical intervention,and the control group received routine nursing.The intervention lasted for three months.After the intervention,the differences on nutrition intake,visual function,nutritional knowledge and social psychological indicators were evaluated between the two groups.At the same time,a qualitative study was used to explore the experience and feelings among eleven AMD patients on the whole intervention program.Results:1.Dietary nutrition status and nutritional management needs of AMD patientsResults of the cross-sectional survey:(1)Referring to the "Reference Intakes of Dietary Nutrients for Chinese Residents",the daily per capita total energy and protein intakes of men with AMD were lower than the recommended intakes.In terms of energy supply ratio,the energy supply ratio of carbohydrates for women meets the recommended requirement(51.67±12.37)%,while the ratio of protein and fat energy supply is higher than the recommended upper limit requirement,respectively(15.47±4.66)% and(32.89 ±10.94)%.The ratio of energy supply from carbohydrates in men was(48.14±16.44)%lower than the recommended lower limit requirement,while the ratio of energy supply from protein and fat was higher than the recommended upper limit requirement,respectively(16.01±5.13)% and(35.74±14.09)%.(2)The daily per capita intake of copper and iron for both sexes and women met the recommended intake standards;while the daily per capita intake of zinc,calcium,lutein,vitamin A,vitamin C,vitamin D,vitamin E and folic acid for men and women Intake of less than 90% of the recommended intake indicates an inadequate intake.(3)The daily intake of vegetables,milk and dairy products in the patient’s dietary structure were 149.97 g and 280.39 g respectively,which did not reach the minimum value recommended by the Chinese residents’ dietary pagoda.The daily intakes of livestock and poultry meat and oily foods are 99.48 g and 50.27 g respectively,which obviously exceed the highest value recommended by the dietary pagoda.The daily intake of cereals and potatoes,fruits,fish and shrimp and eggs are 310.73 g,258.14 g,48.96 g and 45.00 g respectively,which were within the recommended range of the dietary pagoda.(4)The measurement and evaluation of BMI showed that there were 32 patients with BMI ≥ 24,accounting for14.88%.One patient was with BMI<18.5,accounting for 0.47%.There were 182 patients with 18.5 ≤ BMI<24,accounting for 84.65%,indicating that most of the patients had normal nutrition.In the qualitative research,three themes and six sub-themes are obtained for the influencing factors based on COM-B model.The first was ability,including mental ability(lack of relevant nutrition knowledge,misunderstanding of disease and treatment,knowledge conflict)and physical ability(activity restriction,unplanned dietary adjustment,single access to nutrition knowledge);The second was opportunity,including the physical opportunity(doctor-patient communication,health insurance and additional costs,external environment)and social opportunity(stigma and fear of exposure,family influence);The third was motivation,including reflexive motivation(self-efficacy,attitudes,expectations of intervention effects,lack of supervision)and automatic motivation(difficulty changing eating habits,mindset).In terms of nutritional management needs of patients,three themes have been extracted,including professional and continuous nutritional guidance,diversified information acquisition channels,and look forward to modernized and personalized nutrition aids.2.Outcomes of integrating evidence of nutrition intervention for AMD patientsA total of 879 relevant literatures were obtained through preliminary search,and 24 relevant evidences were finally obtained after systematic screening.Among them,there were twenty-two clinical guidelines,seven systematic reviews,one randomized control study,one quasi-trial,one cross-sectional study and two case-control studies.The nutrition-related evidence of AMD patients was summarized,and the evidence was synthesized to form 4 aspects and 16 best evidences including nutrition risk screening and assessment of AMD patients,nutritional intervention(prevention,early,middle and late)measures,nutritional intervention model and health education.3.Constructing a whole-course nutrition management program for AMD patientsThe final core indicators of AMD’s whole-course nutritional intervention program was formed by Delphi method of expert consultation including 6 first-level indicators,20second-level indicators,and 26 third-level indicators.Based on the constructed core index system,the corresponding APP intervention modules and specific intervention steps were designed,and the expert working group method was used to evaluate and revise.The functional modules of AMD nutritional intervention were constructed,including basic modules(user information and system introduction)and nutritional intervention modules(nutritional assessment,nutritional education,nutritional prescription and risk management).Specific intervention steps were also formed including intervention time,location,intervener and object,intervention method,intervention content,intervention strategy,and effect evaluation time and tools.4.Designing and developing a whole-process nutrition management application program for AMD patientsThe background management system of mobile phone and PC were developed by the programmer based on the project design module.During the whole development process,the modules were used and tested many times.The parts in doubt were recorded and gave feedback to the engineers for modification in time.After the development was completed,6patients were selected to conduct a functional usability test on the patient terminal.The feedback and modification were performed to contruct the final version of the AMD whole-process nutrition management application.The running test shows that the application program design interface is beautiful and simple,the content is rich,the function setting is reasonable and the operation process is simple,and has been approved with the computer software copyright certificate of the People’s Republic of China.5.Study of the effectiveness of the whole-course nutrition management program for AMD patients based on mobile medical applicationsQuantitative research results:(1)Among the three functional substances,the energy and protein intake of the experimental group were significantly higher than those of the control group,and the fat intake was significantly lower than that of the control group,the difference was statistically significant(P<0.05);(2)Among the three functional substances,the energy and protein intake of the experimental group were significantly higher than those of the control group,and the fat intake was significantly lower than that of the control group,the difference was statistically significant(P<0.05);Among various nutrients,the intake of zinc,copper,calcium,lutein,vitamin C and vitamin E in the experimental group was significantly higher than that in the control group,and the difference was statistically significant(P<0.01);There was no significant difference in the intake of iron,vitamin A,vitamin D and folic acid in the test group and the control group;(3)The CMT values of the left and right eyes of the test group were significantly lower than those of the control group after the intervention(P<0.05);(4)The total quality of life score in the intervention group was higher than that in the control group after the intervention(P<0.05);(5)The level of nutrition knowledge in the experimental group was significantly higher than that in the control group,and the difference was statistically significant(P<0.001);(6)The level of self-efficacy in the experimental group was significantly higher than that in the control group,and the difference was statistically significant(P<0.001).Qualitative research results,the themes that were extracted include: increase awareness of nutritional intervention and focus on their own dietary health;enhance self-efficacy;promote effective doctor-patient communication;the application is novel and modern,and the content of the intervention is comprehensive.Conclusion:At present,nutritional intervention is one of the important means to prevent and slow down the AMD.Using the Internet and smart phone programs as carriers to provide timely,sufficient,efficient and personalized nutritional support for patients has gradually attracted the attention of ophthalmologists at home and abroad.Therefore,it is of great significance to construct whole-process nutrition intervention program for AMD patients:1.The AMD patients have obvious irrationality in dietary intake and dietary structure,and nutritional intervention is affected by many factors.Therefore,in the process of formulating intervention measures,the patient’s current situation,influencing factors,and individual needs should be fully considered to formulate intervention strategies comprehensively.2.It was showed by the effectiveness of the whole-course nutritional intervention program based on the m Health for AMD that it could improve daily intake of core nutrients,visual function,quality of life,nutritional knowledge and nutritional self-efficacy.The new m Health nutritional intervention was verified as an advanced,efficient and systematic method to provide nutritional support services.And it was more efficient,rapid,accurate and diverse in forms than traditional We Chat and telephone interventions.In conclude,it had better clinical value and development prospect.3.The clinical application test and evaluation show that the application has good clinical application effect and can provide a more convenient and systematic way for medical staff to develop the path and plan of the whole process nutrition management plan and improve the ability of the whole process nutrition management.Additionally,with the development of modern information technology,the development of diversified social media platforms and the selection of the most suitable intervention platform according to the different needs of patients could promote patient compliance to a greater extent.With the aging of population,the prevalence of AMD and the various economic and social burdens will further increase.The APP based overall nutrition management model for AMD will increasingly reflect more obvious advantages and development prospects. |
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