receiving the intervention had significantly greater reductions in dietary total fat, saturated fat, and cholesterol both 6 and 12 months after the initiation of the intervention.
2.4.6 Diet Quality
Manios and colleagues evaluated the effectiveness of a nutrition education program on postmenopausal women (mean age 60 years) in a randomized clinical trial(31).Women were randomized to either a dietary intervention group and attended regular nutrition education sessions for 5 months based on a combined application of the Health Belief Model(32)and the Social Cognitive Theory or to a control group. The goal of the intervention group was to increase nutritional knowledge and self-efficacy of the subjects to adopt and maintain healthy dietary choices as assessed by the Healthy Eating Index (HEI). Subjects in the interven- tion group increased selected individual HEI scores to a significantly greater degree compared with the control group at the end of the intervention period;
however, there were no significant changes in total HEI scores between the groups.
2.5 PRACTICAL APPLICATIONS OF BEHAVIORAL THEORY
Table 2.3
Practical applications of behavioral theory for nutrition interventions in older adults Social Ecologic Theory or
Ecologic Perspective
Prior to the delivery of any effective dietary
counseling, it is necessary to have an appreciation of the patient’s environment. Some areas to probe might include
! The people, places, things that affect the foods consumed. Where does the patient live and with whom? It is helpful to have the ages and relationships of the people living and eating with the patient as dietary choices may reflect others’ preferences
! The dietary preferences and customs. Completing a simple 24-hour dietary recall or asking what a typical breakfast, lunch, dinner, and snack the past week included can provide a wealth of information. It may be the patient’s diet needs only a simple tweaking to comply with the dietary recommendation and not a major overall. Dietary restrictions and current nutritional therapy being employed may or may not be apparent from the recall. Ask what dietary regime has been
prescribed and adherence to those recommendations the past 7 days
! Primary person(s) responsible for the purchase and preparation of the food. If there is a person, other than or in addition to the patient, responsible for meals, the counseling session should include them
! Where meals are eaten?If a person eats all meals at fast food places, restaurants, or community centers, counseling instructions to purchase and prepare meals for home is unlikely to be
accomplished. How can the dietary therapy be tailored to fit into the patient’s current lifestyle?
Health Belief Model Have the patient verbalize what ‘‘he believes’’ his health status to be and listen for words and phrases that would indicate he feels that making dietary changes would be of benefit to his health and quality of life. Ask ‘‘If you made no changes in your dietary habits and you continue eating with no regard for improving your health, what will life be like for you this time next year/in 5 years?’’ After getting responses, flip the question to say ‘‘If you made the dietary changes recommended as a part of the therapy for your disease, how do you see life 3 months from now?’’ The discussion can be directed to repeating to the patient those benefits that are more immediately measured, i.e., lab values, blood pressure, weight, blood sugar
(continued )
28 Shikany et al.
Table 2.3 (continued)
Stages of Change Model Assess the patient’s ‘‘readiness’’ to engage in the dietary behaviors to improve health. Counseling patients and/
or their caregivers who are at a precontemplation or contemplation phase is very different than counseling those who are in the action and maintenance phase (see Table 2.1).There may be other factors that are of higher priority to the patient than making dietary change, i.e., financial concerns, care of a family member, divorce, recent death of a loved one, loss of job.
A question to ask might be ‘‘On a scale of 1–10, how confident are you that in the next week you will be able to prepare five of your seven dinner meals at home?’’ One (1) being you are not at all confident you will be able to do this and 10 being I know for sure I can prepare five of my seven dinner meals at home.
Exploring the number given will give the counselor information on how best to address the nutritional therapy and plans for future counseling sessions Social Cognitive Theory Incorporating principles such as setting goals,
breaking larger goal down to smaller more manageable steps, and building on the success of each step promotes self-efficacy. The patient will feel successful and good about his ability to accomplish goals. Information overload can and will stop the learning and behavioral change process, decreasing the motivation to move forward
Theory of Meaningful Learning
Information from the educational materials and counseling session must have meaning to the patient. The patient should understand what is being asked of her since she is ultimately the person in charge of herself (in most cases). Use terminology familiar to the patient and utilize information obtained from the 24-hour dietary recall and environmental survey to individualize the dietary goals. Know that the patient may feel
uncomfortable asking questions or admitting a lack of understanding
Information Processing Model Look and listen for understanding. Stop to ask open- ended questions of the patient on how specific dietary change(s) might be accomplished. ‘‘To eat fruit in place of the candy bar for afternoon snack will require that you have fruit readily available.’’
What do you need to do to have that fruit available?
Walking the patient through making a grocery list, buying the fruit, and eating it for the snack is helpful. Visualize the process with the patient Chapter 2/ Behavioral Theories Applied to Nutritional Therapies 29