Kathryn S. Keim

State of the Evidence Regarding Behavior Change Theories and Strategies in Nutrition Counseling to Facilitate Health and Food Behavior Change

Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.

Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Nonnutritive Sweeteners

It is the position of the Academy of Nutrition and Dietetics that consumers can safely enjoy a range of nutritive sweeteners and nonnutritive sweeteners (NNS) when consumed within an eating plan that is guided by current federal nutrition recommendations, such as the Dietary Guidelines for Americans and the Dietary Reference Intakes, as well as individual health goals and personal preference. A preference for sweet taste is innate and sweeteners can increase the pleasure of eating. Nutritive sweeteners contain carbohydrate and provide energy. They occur naturally in foods or may be added in food processing or by consumers before consumption. Higher intake of added sugars is associated with higher energy intake and lower diet quality, which can increase the risk for obesity, prediabetes, type 2 diabetes, and cardiovascular disease. On average, adults in the United States consume 14.6% of energy from added sugars. Polyols (also referred to as sugar alcohols) add sweetness with less energy and may reduce risk for dental caries. Foods containing polyols and/or no added sugars can, within food labeling guidelines, be labeled as sugar-free. NNS are those that sweeten with minimal or no carbohydrate or energy. They are regulated by the Food and Drug Administration as food additives or generally recognized as safe. The Food and Drug Administration approval process includes determination of probable intake, cumulative effect from all uses, and toxicology studies in animals. Seven NNS are approved for use in the United States: acesulfame K, aspartame, luo han guo fruit extract, neotame, saccharin, stevia, and sucralose. They have different functional properties that may affect perceived taste or use in different food applications. All NNS approved for use in the United States are determined to be safe.

Among Young Adults, College Students and Graduates Practiced more Healthful Habits and made more Healthful Food Choices than did Nonstudents

OBJECTIVES Health-related characteristics and habits and food choices of young adults were compared for three groups: college students, college graduates, and nonstudents. DESIGN Subjects completed a mailed survey that included questions about demographics, attitudes, and behaviors and a food frequency questionnaire. Main outcome measures were health-related characteristics and habits and food choices. SUBJECTS Female (n = 758) and male (n = 580) 18- to 24-year-olds in nine states who were selected randomly by zip code in each state. The response rate averaged 43% for all states. STATISTICAL ANALYSES PERFORMED Analysis of variance of chi 2 tests were applied to health-related personal characteristic variables and the Kruskal-Wallis analysis of variance was applied to food consumption variables for women and men separately. RESULTS According to self-reported heights and weights, female nonstudents were more often overweight than female students or graduates. Nonstudents of both genders reported smoking more often than students or graduates. College students and graduates ate more grain foods high in dietary fiber, more fruits and dark-green vegetables, and more lower-fat milk and meats than nonstudents. CONCLUSIONS/APPLICATIONS Nonstudents were at greater health risk for some chronic illnesses, because of poorer health habits and food choices, than were college students and graduates. The behavior of nonstudents implies weaker response to messages promoting weight control, smoking cessation, and observance of the Dietary Guidelines for Americans than behavior exhibited by students or college graduates. Health promotion efforts could be enhanced by identifying demographic, educational, situational, and formative influences on positive health and dietary behaviors of young adults.

The Use of Prealbumin and C-Reactive Protein for Monitoring Nutrition Support in Adult Patients Receiving Enteral Nutrition in an Urban Medical Center

BACKGROUND Serum prealbumin (PAB) is commonly used to assess protein status and is often used to monitor the response to nutrition support. However, during inflammation, the liver synthesizes acute-phase proteins such as C-reactive protein (CRP) at the expense of PAB. OBJECTIVE The purpose of this retrospective study was to determine whether changes in PAB reflect the delivery of adequate nutrients or changes in inflammatory status in hospitalized adults (≥18 years) receiving enteral nutrition (n = 154). METHODS Protein and energy intake were compared to changes in PAB, assessed at baseline and twice weekly. C-reactive protein was assessed when PAB was <18 mg/dL to determine the presence and severity of inflammation. RESULTS In a sample of mostly critically ill patients, there was no significant difference in change in PAB for those receiving ≥60% of calorie needs (2.74 ± 9.50 mg/dL) compared to <60% of calorie needs (2.48 ± 9.36 mg/dL; P = .86). Changes in PAB correlated only with changes in CRP (r = -0.544, P < .001). In a subgroup analysis of 62 patients with repeated measures of PAB and CRP, PAB increased significantly only in the bottom 2 tertiles for calorie delivery and the lowest tertile for protein delivery. CONCLUSIONS These results indicate that PAB may not be a sensitive marker for evaluating the adequacy of nutrition support in critically ill patients with inflammation. Only change in CRP was able to significantly predict changes in PAB, suggesting that an improvement in inflammation, rather than nutrient intake, was responsible for the increases in PAB levels.

Vegetable and Fruit Intake and Perceptions of Selected Young Adults

Abstract A mail survey was developed to determine the behaviors associated with eating vegetables and fruits and if there was a relationship between young adults’ perceptions of vegetables and fruits and relative intake. The survey collected demographic information and used a repertory grid and a food frequency questionnaire. Respondents included 219 males and 289 females. The most frequently eaten vegetables and fruits were orange or grapefruit juice, French fries and fried potatoes, other potatoes, other fruit juice, and green salad. Many of the respondents added fat to cooked vegetables and salads. Few respondents ate vegetables at lunch, dinner, or snack time or fruit for desserts or snacks. Students had fewer behaviors where they added fat to vegetables and salads and were more likely to eat vegetables at lunch and snack time. The factor analyses showed perceptions about vegetables and fruits that included both social and sensory aspects and health aspects. Only perceptions of social and sensory aspects of vegetables and fruits were related to intake. Perceptions of health aspects of vegetables and fruits did not have a consistent or significant relationship with intake. The results suggest that social and sensory aspects of vegetables and fruits may be important messages to include in nutrition education programming for young adults.

Emic perspectives of body weight in overweight and obese white women with limited income.

OBJECTIVE The purpose of this study was to develop an understanding of body weight from emic perspectives of limited-income overweight and obese white women. DESIGN In-depth individual interviews, including the use of contour drawings and body dissatisfaction parameters. SETTING All methods were conducted in the homes of the research participants. PARTICIPANTS A purposeful sample of limited-income white women (N=25), ages 19 to 44 years. PHENOMENA OF INTEREST Personal perceptions of attractiveness, health, body weight, and body dissatisfaction. ANALYSIS Transcripts were analyzed using content analysis. Triangulation of data was achieved by comparing data elicited by different methods in different sections of the interview. RESULTS Disordered eating habits were common and considered consequences of social, economic, and familial pressures. Food was often used as a means of coping with life pressures. Social and economic barriers were identified as impeding the adoption of more healthful lifestyles. Weight loss was a low priority owing to financial, emotional, familial, and health care constraints. CONCLUSIONS AND IMPLICATIONS Multidisciplinary programs addressing financial, emotional, and nutritional concerns may be the most effective for weight management among white limited-income women. Additional research is necessary to verify the results of this study with larger samples.

Focus Group Methodology: Adapting the Process for Low-Income Adults and Children of Hispanic and Caucasian Ethnicity

Focus group discussions are being used more often during the formative phase of nutrition education program development. This article discusses focus group procedure adaptations to increase effectiveness with low-income Caucasian and Hispanic audiences for adults and thirdgrade children. Recruitment is more effective if the target audience knows the recruiter. Methods such as posters and letters do not work. The facility needs to be considered safe and easy to get to. Some children need focus group discussions of less than 1 hour in length or some type of activity to break the monotony of the session. The use of a “talking stick” is also helpful to allow all children to be heard. It was observed that the Hispanic participants were not as verbal as the Caucasian participants. More Hispanic focus groups needed to be conducted to obtain the same amount of diversity in information as was obtained from the Caucasian groups.

Concepts of Healthful Food among Low-Income African American Women.

OBJECTIVE Describe beliefs about what makes foods healthful among low-income African American women. METHODS In one-on-one interviews, 28 low-income African American mothers viewed 30 pairs of familiar foods and explained which food in the pair was more healthful and why. Responses were grouped into codes describing concepts of food healthfulness. RESULTS Nutrient content, physical effects of food, and food categories were used to judge the healthfulness of foods. Fruits, vegetables, and dairy foods were considered the most healthful and starchy foods the least healthful because they were believed to cause weight gain. Beliefs about which foods contain which nutrients and which foods have particular physical effects varied widely across participants. CONCLUSIONS AND IMPLICATIONS Participants demonstrated awareness of which foods are healthful but lacked understanding of why those foods are more healthful than others. Knowledge about the health effects of foods may be necessary to motivate individuals to choose healthful foods.

Cultural Perceptions of Health and Diabetes among Native American Men

Diabetes continues to affect minority populations disproportionately, especially Native Americans. Identifying culturally-specific definitions of health and diabetes is critically important for relevant and effective diabetes prevention programs. Qualitative interviews were conducted with 20 Native American men from two tribal clinics. Verbatim transcripts were analyzed by means of grounded theory, to identify culturally-specific definitions of health and diabetes. The men defined health in terms of physical capabilities and presence of disease. Conversely, the men viewed diabetes as an inexorable downward course that slowly manifests itself through various complications and ultimately results in death. Men feared for their own diagnoses as well as the diagnosis of family or community members whom they considered to be at-risk. Additional information about the perceptions of health and diabetes in racial and ethnic minority populations will significantly contribute to the development of effective diabetes prevention programs.

Dietetics Professionals have a Positive Perception of Professional Development

This study summarizes the perceptions towards the Professional Development Portfolio method of recertification and attitude towards professional development of dietetic professionals as measured in the national pilot study of the Portfolio. Portfolio compared to control respondents had greater awareness, and better understanding and knowledge of the Portfolio process after using the Portfolio guide. The perception that the Portfolio process will aid in maintaining competence did not differ between groups. The perception that self-reflection aided in determining career goals and confidence to conduct a learning needs assessment differed slightly between groups. Both groups had a positive attitude towards professional development and that continuing professional education (CPE) improved competence. All perceptions and attitudes were positive. The focus of CPE in foods, business, management, education, and research did affect the ability of dietetics professionals to find appropriate CPE. Rural and unemployed respondents had more difficulty finding appropriate CPE. The findings indicate that the Portfolio guide aides the dietetics professional using the Portfolio process and that the perception towards the Portfolio process is positive. Some dietetics professionals with different CPE focus had difficulty finding appropriate CPE, and this did not differ by control and Portfolio group. More innovative methods of CPE delivery may need to be considered for these practitioners.