Susan Nitzke

Position of the Academy of Nutrition and Dietetics: Total Diet Approach to Healthy Eating

It is the position of the Academy of Nutrition and Dietetics that the total diet or overall pattern of food eaten is the most important focus of healthy eating. All foods can fit within this pattern if consumed in moderation with appropriate portion size and combined with physical activity. The Academy strives to communicate healthy eating messages that emphasize a balance of food and beverages within energy needs, rather than any one food or meal. Public policies and dietary patterns that support the total diet approach include the 2010 Dietary Guidelines for Americans, DASH (Dietary Approaches to Stop Hypertension) Diet, MyPlate, Lets Move, Nutrition Facts labels, Healthy People 2020, and the Dietary Reference Intakes. In contrast to the total diet approach, classification of specific foods as good or bad is overly simplistic and can foster unhealthy eating behaviors. Alternative approaches are necessary in some situations. Eating practices are dynamic and influenced by many factors, including taste and food preferences, weight concerns, physiology, time and convenience, environment, abundance of foods, economics, media/marketing, perceived product safety, culture, and attitudes/beliefs. To increase the effectiveness of nutrition education in promoting sensible food choices, skilled food and nutrition practitioners utilize appropriate behavioral theory and evidence-based strategies. Focusing on variety, moderation, and proportionality in the context of a healthy lifestyle, rather than targeting specific nutrients or foods, can help reduce consumer confusion and prevent unnecessary reliance on supplements. Proactive, empowering, and practical messages that emphasize the total diet approach promote positive lifestyle changes.

The Importance of Decisional Balance and Self-efficacy in Relation to Stages of Change for Fruit and Vegetable Intakes by Young Adults

Purpose. To examine the stages of change, decisional balance, and self-efficacy constructs in relation to fruit and vegetable intakes by young adults 18–24 years old. Design. A cross-sectional project was conducted by 10 states in January–July 2000 to examine decisional balance and self-efficacy in relation to stage of change for increasing fruit and vegetable intake among young adults. Subjects. In all, 1545 usable surveys were returned (response rate = 55%). More non-respondents were men and precontemplators than respondents. Sixty-one percent of respondents were women, 90.3% were white, and 49.7% were current students. Setting. Alabama, Kansas, Maine, Michigan, Nebraska, New York, Rhode Island, Oregon, South Dakota, and Wisconsin. Measures. A telephone screening interview and a self-administered mail survey. Analysis. Analysis of variance, principal components analysis, cluster analysis, and χ2 test. Results. From precontemplation to maintenance, a significant linear trend was found toward higher food intake and self-efficacy for fruits and vegetables. The patterns of shifts in the pros and cons across the stages resembled those of other health behaviors. The decisional balance items were further classified into five component factors that varied significantly in importance across the stages. Four subject clusters were derived (unconcerned, reluctant, exploring, and action-oriented); distribution of the clusters agreed with that of the five stages. Conclusions. This study supports applicability of the Transtheoretical Model for assessing fruit and vegetable consumption by young adults. Derivation of the four clusters implies the importance of including decisional balance and self-efficacy as outcome measures besides dietary behavior for evaluating the effectiveness of nutrition interventions.

Supermarket and Grocery Store–Based Interventions to Promote Healthful Food Choices and Eating Practices: A Systematic Review

Introduction Increasingly high rates of obesity have heightened interest among researchers and practitioners in identifying evidence-based interventions to increase access to healthful foods and beverages. Because most food purchasing decisions are made in food stores, such settings are optimal for interventions aimed at influencing these decisions. The objective of this review was to synthesize the evidence on supermarket and grocery store interventions to promote healthful food choices. Methods We searched PubMed through July 2012 to identify original research articles evaluating supermarket and grocery store interventions that promoted healthful food choices. We categorized each intervention by type of intervention strategy and extracted and summarized data on each intervention. We developed a scoring system for evaluating each intervention and assigned points for study design, effectiveness, reach, and availability of evidence. We averaged points for each intervention category and compared the strength of the evidence for each category. Results We identified 58 articles and characterized 33 interventions. We found 7 strategies used alone or in combination. The most frequently used strategy was the combination of point-of-purchase and promotion and advertising (15 interventions); evidence for this category was scored as sufficient. On average, of 3 points possible, the intervention categories scored 2.6 for study design, 1.1 for effectiveness, 0.3 for reach, and 2 for availability of evidence. Three categories showed sufficient evidence; 4 showed insufficient evidence; none showed strong evidence. Conclusion More rigorous testing of interventions aimed at improving food and beverage choices in food stores, including their effect on diet and health outcomes, is needed.

Participant recruitment and retention in a pilot program to prevent weight gain in low-income overweight and obese mothers

BackgroundRecruitment and retention are key functions for programs promoting nutrition and other lifestyle behavioral changes in low-income populations. This paper describes strategies for recruitment and retention and presents predictors of early (two-month post intervention) and late (eight-month post intervention) dropout (non retention) and overall retention among young, low-income overweight and obese mothers participating in a community-based randomized pilot trial called Mothers In Motion.MethodsLow-income overweight and obese African American and white mothers ages 18 to 34 were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children in southern Michigan. Participants (n = 129) were randomly assigned to an intervention (n = 64) or control (n = 65) group according to a stratification procedure to equalize representation in two racial groups (African American and white) and three body mass index categories (25.0-29.9 kg/m2, 30.0-34.9 kg/m2, and 35.0-39.9 kg/m2). The 10-week theory-based culturally sensitive intervention focused on healthy eating, physical activity, and stress management messages that were delivered via an interactive DVD and reinforced by five peer-support group teleconferences. Forward stepwise multiple logistic regression was performed to examine whether dietary fat, fruit and vegetable intake behaviors, physical activity, perceived stress, positive and negative affect, depression, and race predicted dropout as data were collected two-month and eight-month after the active intervention phase.ResultsTrained personnel were successful in recruiting subjects. Increased level of depression was a predictor of early dropout (odds ratio = 1.04; 95% CI = 1.00, 1.08; p = 0.03). Greater stress predicted late dropout (odds ratio = 0.20; 95% CI = 0.00, 0.37; p = 0.01). Dietary fat, fruit, and vegetable intake behaviors, physical activity, positive and negative affect, and race were not associated with either early or late dropout. Less negative affect was a marginal predictor of participant retention (odds ratio = 0.57; 95% CI = 0.31, 1.03; p = 0.06).ConclusionDropout rates in this study were higher for participants who reported higher levels of depression and stress.Trial registrationCurrent Controlled Trials NCT00944060

Internet-based Interventions Have Potential to Affect Short-term Mediators and Indicators of Dietary Behavior of Young Adults

OBJECTIVE Evaluate a theory-based, Internet-delivered nutrition education module. DESIGN Randomized, treatment-control design with pre-post intervention assessments. SETTING AND PARTICIPANTS Convenience sample of 160 young adults (aged 18-24) recruited by community educators in 4 states. Study completers (n = 96) included a mix of racial/ethnic groups and family demographics, but were predominately white females without children. INTERVENTION A Transtheoretical Model (TTM)-based, stage-tailored Internet program, F&V (Fruit & Vegetable) Express Bites, was delivered to treatment group participants; controls received nontailored messages in a comparable format. MAIN OUTCOME MEASURES AND ANALYSIS: TTM constructs at baseline, immediately postviewing, and at 30-day follow-up were compared via chi-square, McNemars test, and logistic regression. Qualitative use and acceptability indicators were collected postviewing (treatment only). RESULTS Of baseline respondents, 86.5% completed the study. At follow-up, self-efficacy, decisional balance, and selected processes improved for both groups, with only marginal advantages for the theory-based version. Fruit and vegetable consumption changes were similar for both groups. Qualitative measures of knowledge, confidence, and motivation improved (not measured for controls). Favorable ratings of treatment program acceptability and personal relevance were reported. CONCLUSIONS AND IMPLICATIONS The Internet is a favorable option for reaching young adults with nutrition messages. This study did not identify strong advantages of theory-based tailoring, especially for fruit consumption, which had weaker barriers than vegetable consumption among this target audience.

A Stage-of-Change Classification System Based on Actions and Beliefs Regarding Dietary Fat and Fiber

Purpose. The objectives of this study were to develop a stage-of-change classification system and to determine the degree to which various adult subgroups have adopted the behavioral changes necessary to achieve a low-fat and/or high-fiber diet as recommended by the Dietary Guidelines for Americans. Design. The study used a mail survey randomly sent to 7110 adults. Setting. The survey was conducted in 11 states and the District of Columbia. Subjects. The random sample included males and females over age 18. Of the eligible respondents, 3198 (51.5%) were included in this analysis, with 2004 and 2066 unambiguously classified into stages of change for fat and fiber, respectively. Measures. Stage of change was defined by an algorithm based on self-reported intent and behaviors to limit fat and/or increase fiber. Results. 45% of the respondents were classified as being in action/maintenance for fat and 38% for fiber. Women, older adults, individuals with advanced education, persons with diet-related chronic disease, people with higher levels of relevant nutrition knowledge and attitudes, and persons who indicated that health concerns were a primary influence on their diet were more likely to be in action/maintenance than other respondents. Conclusions. The algorithm in this study presents a model that more closely reflects the proportions of the adult population that have achieved low-fat diets and classifies a greater proportion in the preparation stage than classification systems in previous studies.

Self-efficacy, perceived benefits, and weight satisfaction discriminate among stages of change for fruit and vegetable intakes for young men and women

This study determined whether psychosocial, weight satisfaction, and dietary pattern variables discriminate between the Stages of Change for fruit and vegetable intakes among young men and women. A random sample of 18 to 24 year-olds, from 10 states returned 1438 surveys. Discriminant analyses for fruit intake conveyed that between precontemplation and contemplation/preparation, pro-scores and self-efficacy predicted the mens but not womens stages. Between contemplation/preparation and action/maintenance, self-efficacy and breakfast consumption best predicted stage for women, whereas men were discriminated only by self-efficacy. Discriminant analyses for vegetable intake were similar by gender. Precontemplation and contemplation/preparation were discriminated by pro-score and staging into contemplation/preparation versus action/maintenance was best predicted by self-efficacy and weight satisfaction. Young men and women are at different places in the Stages of Change process and few are meeting the vegetable guidelines. Dietary interventions can be most effective if specifically tailored to food group, stage, and gender.

Design and Outcomes of a "Mothers In Motion" Behavioral Intervention Pilot Study.

OBJECTIVE This paper describes the design and findings of a pilot Mothers In Motion (P-MIM) program. DESIGN A randomized controlled trial that collected data via telephone interviews and finger stick at 3 time points: baseline and 2 and 8 months post-intervention. SETTING Three Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) sites in southern Michigan. PARTICIPANTS One hundred and twenty nine overweight and obese African-American and white mothers, 18-34 years old. INTERVENTION The 10-week, theory-based, culturally sensitive intervention messages were delivered via a series of 5 chapters on a DVD and complemented by 5 peer support group teleconferences. MAIN OUTCOME MEASURES Dietary fat, fruit, and vegetable intake; physical activity; stress; feelings; body weight; and blood glucose. ANALYSIS General linear mixed model was applied to assess treatment effects across 2 and 8 months post-intervention. RESULTS No significant effect sizes were found in primary and secondary outcome variables at 2 and 8 months post-intervention. However, changes in body weight and blood glucose showed apparent trends consistent with the studys hypotheses. CONCLUSIONS AND IMPLICATIONS The P-MIM showed promise for preventing weight gain in low-income overweight and obese women. However, a larger experimental trial is warranted to determine the effectiveness of this intervention.

Preschool children's acceptance of a novel vegetable following exposure to messages in a storybook.

OBJECTIVE To investigate whether childrens books affect attitudes and behaviors pertaining to an unfamiliar vegetable. DESIGN Nine Head Start classes were randomly assigned to a positive, negative, or control group. Data were collected through individual interviews on a pretest day and two book-reading (posttest) days. PARTICIPANTS 118 children, ages 3 to 5. INTERVENTIONS Childrens book with prominent positive or negative messages about kohlrabi. MAIN OUTCOME MEASURES Childrens familiarity with kohlrabi, willingness to taste it, and attitudes toward kohlrabi and vegetables in general. ANALYSIS Chi-square and logistic regression. RESULTS There were significantly more kohlrabi tasters in the positive-message group than in the control group during the second posttest (P <.05). Primary factors in willingness to taste kohlrabi during the second posttest were being exposed to the positive-message treatment (P =.0398) and reporting in the previous interview that they would taste kohlrabi again (P =.0026). CONCLUSIONS AND IMPLICATIONS Further study is needed to verify these findings and to determine whether the results generalize to other foods and/or other children.

Predictors of fat intake behavior differ between normal-weight and obese WIC mothers.

Purpose. To determine whether predictors of fat intake behavior were the same for normal-weight and obese WIC mothers when applying the PRECEDE-PROCEED model and to identify predictors for each group. Design. Proportional stratified convenience sampling. Subjects. Five hundred eighty-one nonpregnant, black and white normal-weight (n = 180) or obese (n = 401) women. Settings. The Special Supplemental Nutrition Program for Women, Infants and Children in six counties in southern Wisconsin. Measures. The independent variables were predisposing, enabling, and reinforcing factors. Predisposing factors included beliefs in diet and health, beliefs in diet and body shape, health concerns in food choice, health concerns in nutrition, and eating habits. Enabling factors were cost of food, availability of time to prepare food, and accessibility to purchase food. Reinforcing factors were weight control intentions, sensory appeal, and mood. The dependent variable was fat intake behavior. Structural equation modeling was performed. Results. When controlling for covariates, certain factors affecting fat intake behavior differed between the normal-weight and the obese groups. For the normal-weight group, only reinforcing factors were positively associated with fat intake behavior. For the obese group, reinforcing and enabling, but not predisposing, factors were positively associated with fat intake behavior. Conclusions. Interventions to modify low-income womens fat intake behavior might benefit from targeting behavioral predictors that differ with body size. Messages that emphasize weight control intentions, sensory appeal, and mood are likely to affect both normal-weight and obese women. Information about cost of food, availability of time to prepare food, and accessibility to purchase food is likely to be more effective with obese women.