JMIR Publications

ABSTRACT

Background:

Overweight and obesity are leading threats to individual health and the economy in the United States. Very low-carbohydrate diets can support weight loss and cardiometabolic health, but their translation into primary care remains limited by clinician knowledge gaps, limited visit time, and challenges supporting patients during dietary change. Digital health interventions embedded in the electronic health record may offer scalable strategies for delivering nutrition counseling in primary care.

Objective:

This study aimed to identify barriers and facilitators to patient engagement with Low Carb Journey, a fully automated electronic health record–based nutrition counseling program; barriers and facilitators to low-carbohydrate dietary adherence; and patient-recommended opportunities to improve the program’s content and delivery.

Methods:

We conducted a qualitative study using semi-structured interviews with adult patients enrolled in Low Carb Journey for at least 4 weeks within a large academic health system in the Midwestern United States. Participants were purposively sampled based on program task completion rate to include high engagers, defined as patients who completed at least 50% of assigned tasks, and low engagers, defined as patients who completed no more than 25% of assigned tasks. Interviews were conducted virtually, audio-recorded, transcribed, de-identified, and analyzed using directed content analysis. The study followed the Consolidated Criteria for Reporting Qualitative Research checklist.

Results:

Of 151 invited patients, 22 completed interviews. Seventeen interviews were completed with high engagers and 5 with low engagers. Interview participants were predominantly female and White, and ages ranged from 27 to 74 years. Key barriers to Low Carb Journey engagement included technical challenges with the delivery platform and limited or unclear pre-enrollment counseling by clinicians. Facilitators of engagement included educational content, practical resources, and a supportive program structure. Barriers to low-carbohydrate dietary adherence included cravings for high-carbohydrate foods, social and household challenges, and misalignment of the diet with existing dietary restrictions, preferences, or financial constraints. Facilitators of dietary adherence included ease of finding low-carbohydrate foods, adoption of new dietary habits and routines, and motivation for long-term maintenance of dietary change. Participants recommended additional supplemental resources, preference-aligned dietary advice, less restrictive carbohydrate targets, and content that could be shared with others.

Conclusions:

Low Carb Journey offers a scalable approach for translating evidence-based very low-carbohydrate nutrition counseling into primary care. Findings highlight the importance of a user-friendly delivery platform, clear clinician communication at enrollment, practical and personalized educational content, and resources that accommodate diverse dietary needs, preferences, and financial constraints. Future work is needed to evaluate Low Carb Journey’s clinical effectiveness and refine strategies to personalize nutrition content while preserving scalability. Clinical Trial: NA