ADVANCES IN PRACTICE: EVALUATING CREDIBILITY

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1 Evaluating Credibility of Online Nutrition Information: A Content Analysis on Current Nutrition-Related Blogs Linda Le, MS, RD, LDN Dietitian Brockton Neighborhood Health Center lelinda@bnhc.org Angela Finn, MS Stamford Public Schools Stamford, CT angela.finn@gmail.com Key Words: blog, nutrition blogs, nutrition related health information Abstract Nutrition-related blogs have risen in popularity as more consumers are looking towards the Internet for questions concerning nutrition and health. Currently, there is a lack of standards that ensure reliable and evidence-based content. The objective of this study was to examine characteristics indicating credibility in nutrition-related blogs, comparing differences between blogs authored by nutrition professionals versus nonnutrition professionals. Blogs were analyzed by characteristics including author identification and relation to the nutrition profession, such as a Registered Dietitian (RD), presence of disclaimers, promotion of products or services, and use of evidence-based references. While there was a higher frequency of evidence-based references among blogs authored by RDs compared to non-rds, there was no statistically significant difference in references, disclaimers and promotion of services between RD and non-rd authors. Overall, the majority of nutrition blogs examined were not meeting all characteristics that would indicate credibility, as defined by the researchers, even amongst blogs authored by qualified nutrition professionals. Background Nutrition blogs have risen in popularity as consumers are increasingly looking towards the Internet as a common resource for questions on nutrition and health (1,2). In 2014, about 72% of adults turned to the Internet for health information (3). In healthcare, and more specifically in nutrition and dietetics, social media outlets such as blogs are a common resource that patients and consumers use to access health-related information. Nutrition-related blogs can be defined as webpages devoted to sharing an individual s healthy lifestyle in regards to food and nutrition, while providing an example of healthy living to others (4). Nutrition-related blogs can act as a health education platform with nutrition blogs being more focused on nutritional balance, healthy eating, and wellness. Consumers are increasingly interested in food and nutrition information and those who actively seek information on nutrition and healthful eating has increased from 19% in 2000 to 46% in 2011 and is likely to continue increase (1). With the essence of a blog being an avenue for sharing individual thoughts or opinions, there is a lack of standards for ensuring reliable and evidence-based content. Bloggers conveying nutrition information may not always be the best qualified since education and credentials are not required and consumers may receive information without any filter or rating system to distinguish the source s quality (1). There is a prevalence of nutrition-related blogs promoting disordered eating habits (5) as well as information that may not be following evidence-based recommendations (6); thus the quality of information on social media still raises questions (7). According to one study, only 10% of analyzed websites scored a good score or better in quality (8). The general public may not be aware whether nutrition-related information online is valid, leading to possible misinformed consumers and poor health behaviors and outcomes. Among those who use the Internet, more than 70% report that the health information they find influences a decision about treatment (9). One study found that for online health seekers aged 15-30, one third reported they changed their health behaviors due to searches online (10). Another found that contradictory nutrition information was positively associated with nutrition confusion and levels of backlash (11). This presents a concern for nutritionrelated professionals, specifically Registered Dietitians (RDs), who are educated and trained in the field of nutrition. All RDs are principled to a code of ethics to provide guidance in their professional practice and conduct responsibilities towards the public, to clients, and to the profession (12). The Academy of Nutrition and Dietetics Code of Ethics outlines that the fundamental principles of honesty, integrity, fairness and transparency be applied to all forms of communications and marketing, which include blogging (13). While RDs, nutritionists and general practitioners can be presumed reliable sources for nutrition-related information, there is still a lack of standards to ensure that nutrition-related content displayed on blogs, by both nutrition-related and non-nutrition related authors, is supported by evidence-based research. Social networking for the RD has become a method to communicate and engage peers and the public with the goal of improving health outcomes (13) and also possibly expanding their clientele, products, and services. In order to minimize the potential negative effects of inaccurate health and nutrition information for the general public, nutrition-related blogs should be critiqued towards a standard of acceptability to deem as credible sources of information. The purpose of this study was to examine characteristics indicating credibility in current nutrition-related blogs, and compare differences between blogs authored by nutrition professionals and non-nutrition professionals. The variables of interest included: identification of nationally recognized author credentials, the use of evidencebased references and disclaimers, and the relationship of blog information with promotions and services. Together, this information will contribute to determining how credible nutritionrelated information is on blogs, a popular use of mainstream social media. Renal Nutrition Forum 2018 Vol. 37 No. 1 5

2 Materials and Methods A total of 75 readily accessible nutrition-related blog sites were collected and identified using the Incognito feature of the Google Chrome browser. The use of an Incognito window allowed for private browsing, reducing the influence from previous browsing history. Blog sites were identified by using the search phrases Nutrition Blog, Nutrition Blogspot, and Nutrition Blog Wordpress (14). Blogs needed to be accessible via one direct click of the Google search page and also claim to be a nutrition blog through the name of the website, website link, or within a description on the site. To be accepted for analysis as a popular nutrition blog, sites had to meet inclusion and supplemental criteria, as defined by the researchers in Table 1. Blogs were required to contain at least 50% of nutrition-related posts within the calendar year of 2014 to be included for analysis. The blog also needed to meet at least 1 of 2 supplemental criteria*. These terms were defined as such due to various limitations of blogs and their information available to analyze credibility. Only the first blog post of each month was taken for analysis. Table 1. Criteria for Nutrition Blog Selection Criteria Description Category Inclusion Criteria Supplemental Criteria* Exclusion Criteria Blog website is accessible within one direct click from a Google search engine page, using the specified search phrases Of analyzable posts, at least 50% are nutrition-related At least 1 post per month in 2014 Posts written by an identifiable author via a biography or statement of the author s position relative to the blog Content on veterinary nutrition Content posted prior to or after 2014 Content has no identifiable dates for posts Sites found only from top lists or redirected links *At least one of the two criteria must be included Identifying nutrition blogs discontinued when 25 blogs per search phrase were chosen for analysis, yielding a total of n=75 blogs. When blogs appeared as a result of more than one search phrase, the overlapping blogs were equally and randomly distributed between the search phrases. Twenty-four variables were designed to evaluate the credibility of nutrition-related blogs selected and the nutrition information presented on each of the blogsites. Variables were designed based on blog content characteristics, author identification characteristics, characteristics of references used, characteristics related to the presence of a disclaimer, and characteristics indicating promotional services and received compensation. Additionally, during a pilot analysis, a number of blogs were found to contain nutrition-related online badges recognized throughout the Internet world: RDs4Disclosure and Nutrition Blog Network. Containing an RDs4Disclosure badge on a blog-site indicates the author s commitment to following guiding principles such as transparency about affiliations that may influence one s media outreach (15). Containing a Nutrition Blog Network badge on a blog-site indicates a commitment to providing the public with trusted advice from nutrition experts; the author must be an RD, but not necessarily part of the Academy of Nutrition and Dietetics (The Academy) (16). Presence of these badges may further indicate credibility among nutrition-related blogs and thus were included as characteristics to analyze. Frequency and chi-squared analysis of the collected 75 blog sites were calculated to quantify the blog s characteristics, using SPSS (IBM Corp. Released IBM SPSS Statistics for Windows, Version Armonk, NY). An inter-rater reliability test was conducted using 15 overlapping blogs to ensure that methodology was applied consistently. All overlap met an agreement rate of 93% from a minimum standard of 90%. Table 2. Definitions of Blog Characteristics/Criteria Term Definition Nutrition Blog Nutrition Related Content Disclaimer Identifiable Author Professional Credential Professional Statement Services Offered Academy Related Badge References A website that is regularly updated with posts pertaining to nutrition-related content within the calendar year of The website s content focuses primarily on nutrition topics but can have occasional posts not directly related to nutrition. Posts with text, images, videos, or other multimedia related to nutrition and dietary habits. Content may include research, recipes, and health trends. A statement intended to specify warnings or expectations to the general public in order to fulfill a duty of care owed to prevent unreasonable risk of harm or injury. Defined as having a biography or statement of the person(s) who are noted as the creator of the posts. For our purposes, professional credentials deemed appropriate to provide nutritional information include Registered Dietitian and Medical Doctor (MD). Statement noting professional background and/ or experience in the field. This can include a professional disclaimer. Services solicited on the site may be affiliated with the author or external persons. An online badge such as RDs4Disclosure or Nutrition Blog Network that indicates commitment to a code of ethics related for nutritionists. Posts that include resources where information was taken from evidence-based references, such as a government website (Centers for Disease Control and Prevention or the National Institutes of Health), the Academy of Nutrition and Dietetics, or a peer reviewed scientific journal. 6 Renal Nutrition Forum 2018 Vol. 37 No. 1

3 Results The final sample consisted of 75 blog sites; 58.7% of which identified as being an individual blog with one author, and 41.3% of which identified as being a part of a company or organization. Frequencies of baseline characteristics were categorized into five different themes: blog content, author information, references, disclaimers, and compensation-related frequencies (Graph 1). From the data collected within these frequencies, a guideline to defining a most credible blog site was created. A most credible blog site was defined as one that presented at least one post a month with 75% or more nutrition-related content, one that satisfied both of the supplemental criteria (Table 1), one that presented both a medical and endorsements disclaimer, one that included a professional statement indicating that the author is an RD or MD with clinical nutrition experience, one that provided references and evidence-based sources when applicable, one that included an RDs4Disclosure badge, and one that did not have services associated with blog content. Of all the blogs analyzed, none matched this description completely. Figure 1. Nutrition Blog Characteristics (n=75) There was no significant difference in the chi-squared analysis between characteristics evaluated for credibility among RD authors and non-rd authors. The highest percent difference identified was between the uses of evidence-based references from RD authors to non-rd authors, at 16.1%. The lowest percent difference identified was with regards to promotions of services, at 0.1%. Table 3. Characteristics Evaluated for Credibility among RD and Non-RD Authors (Pearson Chi-squared) Characteristics Author is RD (n) Percent Yes/Some No Difference* Services Offered Own % Other % Both % None % Disclaimer Present Yes % No % Evidence References Never % Sometimes/ % Always Contains Promotions Yes % No % *Percent difference in the chi-squared analysis between characteristics evaluated for credibility among RD authors and non-rd authors. Out of 75 blogs, 46 blogs contained an RD author, while two had a medical doctor (MD). The most common degree identified among authors was a Master s or higher (n=36), however 14 blogs did not provide information on educational background. Only 19 blogs displayed a blog badge, recognized by the Academy; 15 of which contained a Nutrition Blog Network badge, and four that contained both an RDs4Disclosure and Nutrition Blog Network badge. Fifty-five blogs presented at least 75% of posts with nutrition-related content, and 39 blogs presented with both supplemental criteria. Of the 75 blogs analyzed, 33 blogs provided at least one type of disclaimer, 23 blogs provided a medical disclaimer and 22 blogs provided an endorsement disclaimer. Thirty-one blogs offered their own services on the webpage, nine provided other services on the webpage, and 14 provided both their own services and other services on the webpage. Thirty-two blogs contained some type of promotion and 44 received direct compensation. While 54 blogs provided references only sometimes, 11 blogs always provided a reference, and seven blogs always provided evidencebased references. Discussion Dietitians, nutritionists, and general practitioners are the three most preferred sources of nutrition information; they are perceived to be the most educated, trustworthy, and credible (17). While nutrition-related professionals are deemed to be a primary resource, the Internet accounts for 62.9% of received resources, even though it is not always trustworthy or validated (10). At the completion of this content analysis study of nutrition-related blogs, it can be supportively noted that the majority of current blog content found on Internet sources, such as nutrition-related blogs, do not meet many characteristics indicating credibility. This study was a step in determining the relationship between social media and promotion of nutrition-related information with a unique focus on credentialed and non-credentialed authors. There were several limitations to this research. With a small sample size, chi-squared tests could not be done with all variables; a larger content analysis should be done in order to compare all variables to allow for a report on statistical significance, instead of only percent differences. For reasons of feasibility and consistency during a limited research study, one post per month during the 2014 calendar year was analyzed. Renal Nutrition Forum 2018 Vol. 37 No. 1 7

4 Some blogs had several posts a day while others had only one post a month; some posts may not have been analyzed that could have included additional information such as references or disclaimers that were not captured within analyzing the first post of each month. Additionally, the data is limited to the calendar year of 2014 and has not been updated with more currently popular nutrition blogs; due to the fast paced nature of change on the web, blogs analyzed and held relevant in 2014 may not hold true in future years. Lastly, while the use of Google s Incognito window feature allowed for a private search of blogs without having personal browsing history, there may be more nutrition blogs authored by nutrition professionals that could be deemed as credible, however that did not appear within the pages searched for this study. Figure 1 analyzed blog content by characteristics, including the Academy s-recognized badges. Both the RDs4Disclosure badge and Nutrition Blog Network badge indicate some commitment for full disclosure in all forms of media and online communications. RDs are bound by an ethical code of conduct upon credentialing to refrain from the practice of providing false or misleading information to patients, clients, and consumers. A violation of this code would be failure to disclose real or perceived conflicts of interest. The Nutrition Blog Network badge only requires the blog to have an RD author, however the RDs4Disclosure requires authors to agree to additional standards of online conduct. There was a small presence of these badges, with only 19 blogs containing either one or both badges. This indicates that while these badges could be a good indicator of credibility, there is currently not enough widespread use to recommend looking for these as a primary means of identifying a credible blog. Many authors (n = 29) did not include a nutrition-related title indicating completion of supervised practice that made them eligible to provide credible nutrition information (Table 1). As not all blogs have credentialed nutrition professionals on their team of authors, it is important for individuals to be aware if authors who are not recognizably credentialed to provide credible nutrition information run the blog. Individuals who are not credentialed professionals in nutrition providing nutrition information could distribute misinformation given to the public and could lead to physical harm. Though 11 blogs always presented references when applicable, only seven blogs always presented evidence-based references. Presenting references is important for presenting nutrition related information to minimize the amount of bias or misinformation that could be found on nutrition blogs. Evidence-based references are sources that provide scientific research to back up nutrition information that is being talked about in the blog. Since nutrition is a science that is constantly changing according to current research, it is vital that nutrition facts be supported by scientific evidence, regardless of the author s credentials. Presenting a disclaimer is important for blogs in order to protect the author or organization from liability of any information provided. Of the 75 blogs analyzed, only 33 presented a disclaimer, 23 included a medical disclaimer and 22 had an endorsement disclaimer. Since blogs can be accessed by anyone with any type of medical condition, it is important for nutrition blogs to have disclaimers stating that the information provided is not meant to substitute for individual medical advice or treatment. An endorsement disclaimer should be revealed if the owner of the blog is being compensated to provide opinion on products or services. Doing so alerts the reader to any possible bias of nutrition information provided. Unexpectedly, frequencies of the blog s association with services indicated that the majority of blogs analyzed (n=54) were associated with some type of service (including personal businesses, partnerships, or work affiliation). More than half of these blogs are likely being compensated for maintaining a blog site, which may lead to a bias in the nutrition information provided depending on how they are being compensated, by whom, and whether they provide a disclaimer. In this type of relationship on a blog, the presence of an endorsement disclaimer is vital to ensure the information does not reflect bias. Streamlining sponsorship and disclosure is important because although sponsorship type may not have a significant effect on attitude about such posts, consumers are likely to believe the content if they have a positive attitude towards the blogger and thus inform an intention to purchase such products (18). Food companies tend to take interest in sponsorship (19) so it is vital for RDs to be careful as those blogging from a professional perspective had more external links, sponsorship and advertising compared to those blogging from a patient/consumer perspective (20). In this study there was no significant difference between the two. It should be reminded, specifically to RDs, that the Academy reveals suggestions for disclosure of sponsors to maintain being a trustworthy source (1). Many of the characteristics that could measure credibility of a nutrition blog, including services offered, disclaimers, and promotions, show a very minimal percent difference between blogs with RD authors. Although no significant differences were identified to statistically credit any of the blogs that were analyzed, meaningful significance of these results were recognized. There was a higher frequency of evidence-based references among blogs authored by RDs compared to non-rds. There was no difference in frequency of promoting personal services among blogs authored by RDs and non-rds. The only variable where RDs stood out more than the non-rd author was within the usage of evidence-based references; however, even this difference is marginal. Overall, with the data retrieved from SPSS analysis, the majority of nutrition-related blogs examined are not meeting all characteristics that can indicate credibility, even amongst those authored by qualified nutrition professionals; these results indicate that blogs with nationally recognized nutrition professionals are not much different from those without nutritionrelated credentials. Conclusion Although RDs are uniquely qualified to translate evidencebased research into positive and practical food and diet advice for the public (1), many consumers access the Internet seeking 8 Renal Nutrition Forum 2018 Vol. 37 No. 1

5 guidance regarding weight, health, diet, and nutrition through blogs. It is important for health and nutrition-related information made accessible through the Internet to have credible sources; otherwise consumers can be misled by incorrect or biased information, possibly leading to poor health decisions. This study reveals a need for RDs and nutritionally credentialed professionals to maintain an ethical code of conduct to refrain from false or misleading information online, and specifically blogs. This is an opportunity for RDs and other recognized nutrition experts to improve the nutrition-related content they provide on blogs and therefore distinguish themselves from authors that do not have credentials to give nutrition advice. RDs should be recommended authors for nutrition-related blogs because of their expertise and responsibility to the public and profession. Opportunities to distinguish their credentials include RDs avoiding personal services and promotions to create bias in the information they provide and to include evidence-based material to support their claims. We suggest further research may be done on the marketing or other services provided among health websites and blogs. Following the suggestions on the most credible blog, RDs may be able to distinguish themselves positively as trusted resources to the general public, especially those using the Internet and social media outlets as means of receiving nutrition-related information. References 1. Academy of Nutrition and Dietetics. Communicating accurate food and nutrition information. eatrightpro.org/~/media/eatrightpro%20files/practice/ position%20and%20practice%20papers/practice%20papers/ practice%20papers/communicating_accurate_food_and_ nutrition_information.ashx. Accessed on Dec 20, Fiskdal AS, Kumbamu A, Jadhav AS, et al. Evaluating the process of online health information searching: A qualitative approach to exploring consumer perspectives. JMIR. 2014;16(10):e Health fact sheet. (2014). Accessed on Oct 5, Boepple L, Thompson J K. A content analysis of healthy living blogs: Evidence of content thematically consistent with dysfunctional eating attitudes and behaviors. Int J Eat Disord. 2014;47(4): Gies J, Martino S. Uncovering ED: A qualitative analysis of personal blogs managed by individuals with eating disorders. The Qualitative Report. 2014;19(29): Hirasawa S, Yachi Y, Yoshizawa S, et al. Quality and accuracy of Internet information concerning a healthy diet. Int J Food Sci Nutr. 2013; 64(8): Grajales III FJ, Sheps S, Ho K, et al. Social media: A review and tutorial of applications in medicine and health care. JMIR. 2014;16(2):e Weil AG, Bojanowski MW, Jamart J, et al. Evaluation of the quality of information on the internet available to patients undergoing cervical spine surgery. World Neurosurg. 2014; 82(1-2):e31-e39 9. Berland G, Elliott M, McGlynn E, et al. Health information on the Internet: Accessibility, quality and readability in English and Spanish. JAMA. 2001; 285(20): Beck F, Richard JB, Nguyen-Thanh V, et al. Use of the internet as a health information resource among French young adults; Results from a nationally representative survey. JMIR. 2014;16(5):e Nagler RH. Adverse outcomes associated with media exposure to contradictory nutrition messages. J Health Commun. 2014;19(1): Academy of Nutrition and Dietetics. Code of Ethics for the Profession. Available at: media/eatrightpro%20files/career/code%20of%20ethics/ codeofethicsdieteticsresources.ashx. Accessed on Oct 5, Ayres E J. The impact of social media on business and ethical practices in dietetics. J Acad Nutr Diet. 2013;113: The Next Web. Business Apps. The 15 best blogging and publishing platforms on the Internet today. Which blog is for you? Available at: businessapps/2013/08/16/best-blogging-services/#. tnw_1tjkbp4d. Accessed on Dec 10, RDs4Disclosure. Available at: Accessed on Dec10, Nutrition Blog Network. Available at: nutritionblognetwork.com/. Accessed on Dec 10, Cash T, Desbrow B, Leveritt M, Ball L. Utilization and preference of nutrition information sources in Australia. Health Expect. 2015;18(6): Lu L, Chang W, Chang H. Consumer attitudes toward blogger s sponsored recommendations and purchase intention: The effect of sponsorship type, product type, and brand awareness. Comput Human Behav. 2014;34: Lynch M. Healthy habits or damaging diets: An exploratory study of a food blogging community. Ecol Food Nutr. 2010;49(4): Miller EA, Pole A, Bateman C. Variation in health blog features and elements by gender, occupation, and perspective. J Health Commun. 2011;16(7): Renal Nutrition Forum 2018 Vol. 37 No. 1 9