Cheryl Achterberg

Review of Self-Efficacy and Locus of Control for Nutrition- and Health-Related Behavior

This article reviews several cognitive predictors of health- and diet-related behaviors commonly used in theories and models of nutrition and health behavior change. Constructs such as self-efficacy, self-esteem, outcome expectancies, health value, and locus of control are examined. Self-efficacy has repeatedly been a good predictor of health behavior, sometimes explaining more than 50% of variability. Research on locus of control and other predictive factors has been less conclusive. The take-home message is threefold: (a) task specificity of self-efficacy and domain specificity of locus of control are crucial for unraveling their effects on behavior; (b) careful segmentation of different population groups under study may explain the inconsistencies in previous research; and (c) especially when studying dietary behavior, these predictors of behavior change should not be used alone or in place of one another but should be used simultaneously to explain complex food and diet-related behaviors. We recommend that nutritionists systematically integrate available theories and models and explore new areas for studying human behavior, such as sociology and anthropology, to form a more powerful, comprehensive model for behavior change.

Changing the diet of America's children: What works and why?

Executive summary This paper examines educational efforts and programming designed to change the diet of Americas children. These programs are frequently part of school-based nutrition education; however, other outreach methods, including school-wide environmental change efforts, family-focused interventions, mass media messages, community-based interventions, and federally funded nutrition programs, also target eating behavior change in children. We identified six elements of successful nutrition education programming: (1) programs are behaviorally based and theory driven; (2) family involvement is incorporated into programs for elementary-aged children; (3) programs for middle school to senior high students include self-assessment of eating patterns; (4) behavior change programs include intervening in the school environment; (5) behavior change programs include intervening in the larger community; and (6) programs include intensive instruction time. Successful programs included most of the identified elements. Emerging trends and innovative approaches were also reviewed, though few of these have been rigorously evaluated. We found that nutrition education is increasingly included as part of multidisciplinary educational programs. For example, school-based interventions simultaneously target eating and activity behaviors. We also saw a resurgence of integrating nutrition curricular information into other core subject areas. This integration reflects the growing demands on instructional time in our schools. We also found that the mass media is becoming more powerful in influencing the diet of Americas children. This influence occurs not solely through food advertisements targeted at children, but also through industry-sponsored public service announcements and curricula teaching children about basic nutrition concepts. Interactive computer technology is one of the most exciting innovations for nutrition education. Computer-based learning allows children to move at their own pace in instructional settings that require much less teacher time. The recommendations call for five broad-reaching objectives to more effectively improve the diet of American children. Ftrst, schools, school districts, and local, state, and federal governments need to commit to comprehensive, school-based nutrition education. Effective nutrition education requires thoughtful consideration of scope and sequence so that behavioral skills can be established in early elementary grades and enriched with more abstract problem-solving skills in junior and senior high school. Teachers need to be adequately trained, and the school environment must provide healthful options for children. Second, we call for multiple instructional techniques for nutrition education. Didactic lessons are insufficient for behavior change. Experiential, hands-on learning, problem solving in group settings, and interactive computer opportunities will be most effective in promoting learning and behavior change. Third, we call for viewing diet change for children from an environmental perspective that includes family, community, the media, and the food industry. Even the best quality classroom-based education is not sufficient for teaching and modeling healthful eating behavior in children. Children learn about what to eat and why to eat, and are provided reinforcements and incentives for food-related activity from their families and larger environment. If the diet of Americas children is to change for the better, our environment must be supportive. Fourth, it is imperative that rigorous outcome evaluation be an integral part of nutrition education programs developed with the intent of national distribution. Such evaluation may be enriched by forming partnerships that draw on industrys expertise in market research. Lack of outcome evaluation and publication inhibits the acceptance and dissemination of creative and innovative approaches. Simpler evaluation is appropriate for programs disseminated locally. Fifth, it is imperative that federal and state governments develop and/or promote a system to disseminate effective nutrition education materials. Effective materials are underutilized in this country, in part due to unawareness of their existence and in part due to inaccessibility. A clearinghouse or network to collect, describe, rate, and share these programs nationally may be an important first step. Partnerships with industry, professional organizations, and private sources to reproduce and disseminate nutrition education materials may be beneficial as well; however, nutrition educators also need to be encouraged to work collectively, that is, to produce fewer, higher quality materials on the same topics. Incentives should be built into the dissemination system to encourage collective sharing of educational materials. To conclude, we can improve our interventions if the principles presented in this paper are incorporated into nutrition education programming for children. These improvements will require commitment to nutrition education at the federal, state, and local levels and the development of partnerships among government, industry, schools, families, communities, and the media. The benefits of this commitment and partnership will be realized through Americas most precious resource, the health and well-being of our children.

How to Make Nutrition Education More Meaningful Through Facilitated Group Discussions

Facilitated group discussions provide an alternative method to lecture and one-on-one approaches for conducting educational interventions at clinic sites. They are an interactive form of education wherein learners generate the specific topics to be addressed and share their knowledge and experience with other group members through discussion. In brief, the educator becomes a facilitator who, rather than lecturing, encourages clients to discuss freely among themselves their own approach to the nutrition problems posed during the session. As a facilitator, the nutritionist strives to create a comfortable atmosphere for discussion, encourages participation, and interjects only to correct misinformation and manage group dynamics. Facilitated group discussions allow nutrition practitioners to deliver meaningful nutrition education in a manner that helps empower their clients to improve their dietary habits; at the same time such discussions meet the increased public administrative demands for efficiency. Possible benefits to clients include more confidence, better communication skills, improved thinking skills, and increased motivation and commitment to improving nutrition behavior. We recommend that nutrition educators try facilitated group discussions in their clinics.

How to put the food guide pyramid into practice

The Food Guide Pyramid represents changes and challenges for nutrition educators. Nutrition educators will have to change the focus, content, and teaching expectations for lessons. Use of the Pyramid will also require changes in the way the concepts of good nutrition are related to different audiences. In contrast to previous food guides, which represented a foundation diet, the Food Guide Pyramid represents the total diet, addressing overnutrition as well as undernutrition. The Food Guide Pyramid is a graphic representation of the Dietary Guidelines for Americans, and illustrates the key concepts of variety, moderation, and proportionality. For practitioners, one challenge is to find ways to effectively use the Food Guide Pyramid to teach clients how to put the Dietary Guidelines into action. Another challenge involves designing materials that adapt the messages of the Food Guide Pyramid to a variety of audiences. Teaching materials and instructions should emphasize the key concepts of the Food Guide Pyramid and should be clear, consistent, motivational, and culturally sensitive. Few educational materials are available to help practitioners with these challenges. In this article we outline the key changes that the Food Guide Pyramid embodies, and provide ideas and suggestions for using the Pyramid in a practice setting.

Is One Theory Better than Another in Nutrition Education? A Viewpoint: More Is Better

Health behavior theories describe the relations among variables influencing a behavior and specify targets for facilitating behavior change. Nutrition education does not have a dominant theory specific to the discipline. Instead, constructs from multiple theories have been borrowed, primarily from the social sciences, and have been applied to describe or predict nutrition-related behaviors. However, current theories do not fully predict behavior or behavior change. A more effective approach may be to integrate distinct constructs from competing theories into one or more polytheoretical models that can be empirically tested and refined into a more comprehensive, tailored theory or set of theories specific to food and nutrition behavior changes. In our view, more than one will be needed to address the complex array of people, issues, and contexts that we routinely address in nutrition education and behavioral interventions.

Outcomes of a Cardiovascular Nutrition Counseling Program in African-Americans with Elevated Blood Pressure or Cholesterol Level

OBJECTIVE To evaluate a cardiovascular nutrition education package designed for African-American adults with a wide range of literacy skills. DESIGN Comparison of a self-help group and a full-instruction group; each group received nutrition counseling and clinical monitoring every 4 months. SUBJECTS Three hundred thirty African-American adults, aged 40 to 70 years, with elevated cholesterol level or high blood pressure were randomly assigned to the self-help or full-instruction group; 255 completed the 12-month follow-up. INTERVENTIONS Counseling to reduce intake of dietary fat, cholesterol, and sodium was based on Cardiovascular Dietary Education System (CARDES) materials, which included food-picture cards, a nutrition guide (self-help and full-instruction group), a video and audiotape series, and 4 classes (full-instruction group only). MAIN OUTCOME MEASURES Changes in lipid levels and blood pressure after 12 months. STATISTICAL ANALYSES PERFORMED Primary analyses consisted of repeated-measures analysis of variance to examine effects of time and randomization group on outcomes. RESULTS Total cholesterol and low-density lipoprotein cholesterol level decreased by 7% to 8% in the self-help and full-instruction groups of men and women (P < .01). The ratio of total cholesterol to high-density lipoprotein cholesterol (HDL-C) decreased in both groups of women and in the men in the full-instruction group (P < .01). In full-instruction and self-help participants with elevated blood pressure at baseline, systolic blood pressure decreased by 7 to 11 mm Hg and diastolic blood pressure decreased by 4 to 7 mm Hg (P < .01). Outcomes did not differ by literacy scores but were positively related to the reported initial frequency of using CARDES materials. APPLICATIONS/CONCLUSIONS These results suggest that periodic nutrition counseling based on CARDES materials used for home study can enhance management of lipid levels and blood pressure in African-American outpatients.

Knowledge and Misconceptions About the Food Label Among Women With Non-Insulin-Dependent Diabetes Mellitus

Women on restricted diets are reportedly among the most frequent readers of nutrition information on food labels. However, the specific label information that women with non- insulin-dependent diabetes mellitus (NIDDM) comprehend and use has not been determined. The purpose of this study was to explore the attitude toward, use, and knowledge of information on the food label among rural women with NIDDM age 40 to 60 years. Focus groups and in-depth interviews were conducted. Participants reported that they referred to the nutrition information on the label when grocery shopping and preferred the newly revised format. Yet, comprehension of the terms and percentages on the label was poor (eg, the majority of participants could not explain the difference between total carbohydrate and sugars). Misconceptions also were noted about nutrients listed on the label and the percent daily value. Further education is needed to help people with NIDDM understand and apply the nutrition information on food labels to meet their individual needs.

Reliability and validity of a nutrition and food-label knowledge test for women with type 2 diabetes mellitus

Valid and reliable measures of nutrition knowledge are needed for program evaluation to develop predictive models of learning, food intake, and health behavior. The food label is an essential component of diabetes education. This study describes how an instrument designed to assess knowledge of food labels was pretested for reliability and validity. Five people assessed the test for face validity and rated the test at least 4 on a 5-point scale. The index of content validity was 0.76 based on a review of the test by five dietitians. The test was used to evaluate a nutrition intervention for women with diabetes using a pretest/post-test control-group design (n = 43). The coefficient of stability was 0.86 using the test–retest method among participants in the control group. The reliability estimate for internal consistency was 0.81 based on Kuder-Richardson formula 20. Item analysis found individual questions to be within acceptable limits. Participants in the experimental group showed significant gains in knowledge at post-test (p < .01), supporting the instructional sensitivity of the test. The approach used to assess the reliability and validity of an instrument was feasible and effective and is recommended prior to implementing a test for outcome evaluation.

Factors Perceived to Influence Dietary Fat Reduction Behaviors

Abstract Dietary change is an inherently complex process. Although dietary fat reduction is an important issue in nutrition education, factors facilitating this type of change have not been fully examined. By accumulating information from individuals who have already been successful in initiating and maintaining dietary fat reduction, practical means of assisting others can be learned. This study collected information from 155 participants between the ages of 30 and 55. Participants were included if they reported the initiation of sustained dietary fat reduction strategies beginning at least 5 years prior to recruitment. Data used to examine individual patterns of dietary fat reduction were collected via in-depth, semistructured, retrospective interviews. Qualitative analyses identified 134 factors that played a role in facilitating the adoption of multiple fat reduction strategies. The factors identified were further classified into two categories: unplanned and planned. Unplanned factors were defined as life events or occurrences that are not nor should they be intentionally included in ones life as a means of dietary improvement (e.g., market influence, health issues, disease diagnosis). Planned factors were defined as occurrences often intentionally included in ones life to facilitate dietary change (e.g., going on a weight loss diet, acquiring an appliance, making a resolution).They frequently resulted from mediation by an unplanned factor.These factors can be used to help nutrition educators identify specific times conducive to initiating dietary change, as well as techniques for facilitating dietary fat reduction.

Dietary Fat Reduction Strategies Used by a Group of Adults Aged 50 years and Older

OBJECTIVE To investigate the fat-reduction strategies used by a group of older adults who successfully made and maintained positive dietary changes for 5 years or longer. DESIGN Participants completed 2 copies of a self-administered food frequency questionaire: The first copy assessed diet before they began making changes and the second copy assessed diet after initiation of healthful dietary changes. Positive food changes were identified from the food frequency questionnaires. During in-person interviews, participants placed food changes onto a time line according to the nearest estimated date of initiation of the change. SUBJECTS Participants were 65 free-living older adults (aged >50 years) who had maintained substantial changes to decrease fat intake in their diet for at least 5 years. Statistical analyses performed Quantitative and qualitative data were used to identify the fat-reduction strategies and to confirm and validate the fat-reduction strategy model. Confirmatory factor analysis was performed to confirm the new model. The Kuder-Richardson-20 reliability coefficient (kr) was used to determine internal consistency of the scales developed for the study. RESULTS The majority of participants decreased their fat intake gradually, at different time points in their lives, and over a long period of time (5 to 43 years). Mean percent energy intake from fat decreased from 44.3 +/- 5.9% before dietary improvement to 25.9 +/- 7.1% at the time of the study. The final model consisted of 5 fat-reduction strategies with 63 food changes. The strategies were: increase summer fruits (4 items; kr=0.66), increase vegetables and grains (14 items; kr=0.79), decrease recreational foods (14 items; kr=0.76), decrease cooking fat (20 items; kr=0.86), and use fat-modified foods (11 items; kr=0.80). APPLICATIONS/CONCLUSIONS Dietetics professionals should base their advice on the dietary strategies used by consumers rather than hypothetical premises such as food or nutrient groupings. Nutrition education interventions will have better chances for success if they are based on a set of customized programs that guide appropriate consumer segments through a series of small, comfortable, and sustainable dietary changes over a prolonged period of time.