State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change

Development of the Intervention Materials for the HomeStyles Obesity Prevention Program for Parents of Preschoolers

Home environment is key to the development of obesity-preventing behaviors during childhood, yet few resources help preschool parents address factors at home associated with obesity risk. This paper describes creation of materials for an in-home intervention (HomeStyles) with this population. An advisory group of stakeholders and target audience members determined salient factors affecting childhood obesity to address in-home and developed program materials. The Social Cognitive Theory, Faith's Core Behavior Change Strategies to Treat Childhood Obesity, Adult Learning Theory and motivational interviewing techniques guided development of 12 guides targeting strategies parents can use to shape the home environment. Interviews were conducted to determine effectiveness of the guides. Cognitive testing of guide design (n = 251) and content (n = 261) occurred in English and Spanish in New Jersey and Arizona with parents and home visitation staff who would present the guides. Interviews investigated perceptions of content usefulness and parent comprehension. Findings were also examined in light of theoretical underpinnings. Both home visitation staff and parents felt the guides were very readable and useful. Parents appreciated use of motivational interviewing techniques and Adult Learning Theory. Current research is testing these guides through an in-home, randomized control trial.

Eating As Treatment (EAT) study protocol: a stepped-wedge, randomised controlled trial of a health behaviour change intervention provided by dietitians to improve nutrition in patients with head and neck cancer undergoing radiotherapy

INTRODUCTION

Maintaining adequate nutrition for Head and Neck Cancer (HNC) patients is challenging due to both the malignancy and the rigours of radiation treatment. As yet, health behaviour interventions designed to maintain or improve nutrition in patients with HNC have not been evaluated. The proposed trial builds on promising pilot data, and evaluates the effectiveness of a dietitian-delivered health behaviour intervention to reduce malnutrition in patients with HNC undergoing radiotherapy: Eating As Treatment (EAT).

METHODS AND ANALYSIS

A stepped-wedge cluster randomised design will be used. All recruitment hospitals begin in the control condition providing treatment as usual. In a randomly generated order, oncology staff at each hospital will receive 2 days of training in EAT before switching to the intervention condition. Training will be supplemented by ongoing supervision, coaching and a 2-month booster training provided by the research team. EAT is based on established behaviour change counselling methods, including motivational interviewing, cognitive-behavioural therapy, and incorporates clinical practice change theory. It is designed to improve motivation to eat despite a range of barriers (pain, mucositis, nausea, reduced or no saliva, taste changes and appetite loss), and to provide patients with practical behaviour change strategies. EAT will be delivered by dietitians during their usual consultations. 400 patients with HNC (nasopharynx, hypopharynx, oropharynx, oral cavity or larynx), aged 18+, undergoing radiotherapy (>60 Gy) with curative intent, will be recruited from radiotherapy departments at 5 Australian sites. Assessments will be conducted at 4 time points (first and final week of radiotherapy, 4 and 12 weeks postradiotherapy). The primary outcome will be a nutritional status assessment.

ETHICS AND DISSEMINATION

Ethics approval from all relevant bodies has been granted. Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12613000320752.

Development and Validation of the Guide for Effective Nutrition Interventions and Education (GENIE): A Tool for Assessing the Quality of Proposed Nutrition Education Programs

OBJECTIVE

To develop and validate the Guide for Effective Nutrition Interventions and Education (GENIE), a checklist of research-based quality indicators for nutrition education programs.

DESIGN

A prospective test of criterion validity and inter-rater reliability of a new tool comparing expert assessments and trained reviewer GENIE scores of the same nutrition education proposals.

PARTICIPANTS

Ten nutrition education experts; 13 volunteer reviewers.

VARIABLES MEASURED

GENIE's face, content, and criterion validity and inter-rater reliability compared using expert assessments and reviewer objective and subjective scores.

ANALYSIS

Reviewer scores compared using Spearman correlation. Inter-rater reliability tested using intra-class correlation (ICC), Cronbach alpha, and ANOVA. Criterion validity tested using independent t test and point bi-serial correlation to compare reviewer with expert scores.

RESULTS

Correlation found between total objective and total subjective scores. Agreement found between reviewers across proposals and categories considering subjective scores (F = 7.21, P < .001; ICC = 0.76 [confidence interval, 0.53-0.92]) and objective scores (F = 7.88, P < .001; ICC = 0.82 [confidence interval, 0.63-0.94]). Relationship was not significant (r = .564, P = .06) between expert and reviewer proposal scoring groups (high, medium, and low).

CONCLUSIONS AND IMPLICATIONS

Results support the validity and reliability of GENIE as a tool for nutrition education practitioners, researchers, and program funding agencies to accurately assess the quality of a variety of nutrition program plans.

The nutrition consult for recurrent stone formers

Diet is implicated in stone formation and growth. Whether alone or in concert with pharmacologics, dietary changes may be useful in reducing recurrence but only when they correct dietary stone-forming risks. Patients benefit from recommendations individualized to their food preferences as well as to lifestyle, age, food knowledge and access, preparation skills, and cultural and ethnic identities. Urologists can provide general dietary recommendations but often lack the time to provide the full complement of individualized nutrition care offered by a registered dietitian nutritionist (RDN). Urologists can partner with and refer patients to a RDN for any component of the nutrition care process: assessment of diet, diagnosis of dietary factors that contribute to stone risk factors, intervention formulation and implementation, and monitoring the effectiveness of the intervention and modifying it as needed to maintain suitably low dietary risk for stone recurrence.

Effectiveness of lifestyle-based weight loss interventions for adults with type 2 diabetes: a systematic review and meta-analysis

AIMS

To provide a systematic review and meta-analysis of recent evidence on the effectiveness of lifestyle-based weight loss interventions for adults with type 2 diabetes.

METHODS

A search of the literature from January 2003 to July 2013 was conducted (PubMed, Embase, CINAHL and Web of Science). The studies considered eligible were randomized controlled trials evaluating weight loss interventions (diet and physical activity, with or without behavioural strategies) of ≥12 weeks duration, compared with usual care or another comparison intervention. Ten studies were included for review. Some heterogeneity was present in the sample, therefore, random-effects models were used to calculate pooled effects.

RESULTS

Intervention duration ranged from 16 weeks to 9 years, with all but one delivered via individual or group face-to-face sessions. From six studies comparing lifestyle intervention with usual care the pooled effect on weight (n = 5795) was -3.33 kg [95% confidence interval (CI) -5.06, -1.60 kg], and on glycated haemoglobin (HbA1c; n = 5784) was -0.29% (95% CI -0.61, 0.03%), with both attenuated in sensitivity analyses. The pooled within-group effect on weight (n = 3063) from all 10 lifestyle intervention groups was -5.33 kg (95% CI -7.33, -3.34 kg), also attenuated in sensitivity analyses. None of the participant or intervention characteristics examined explained the heterogeneity. Only one study assessed whether intervention effects were maintained after the end of the intervention.

CONCLUSIONS

Lifestyle-based weight loss intervention trials in type 2 diabetes achieve, on average, modest reductions in weight and HbA1c levels, but results were heavily influenced by one trial. Evidence-based approaches for improving the effectiveness of lifestyle-based interventions in type 2 diabetes are needed, along with future studies reporting on maintenance and cost-effectiveness.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot

BACKGROUND CONTEXT

Owing to mobility limitations, people with lumbar spinal stenosis (LSS) are at risk for diseases of inactivity, including obesity. Therefore, weight management in LSS is critical. Body mass index is the strongest predictor of function in LSS, suggesting that weight loss may promote physical activity and provide a unique treatment option. We propose a lifestyle modification approach of physical activity and nutrition education, delivered through an e-health platform.

PURPOSE

The purpose of this study was to develop and pilot an e-health intervention aimed at increasing physical activity and decreasing fat mass in people with LSS.

STUDY DESIGN

The study design was based on intervention development and pilot.

PATIENT SAMPLE

Ten overweight or obese individuals with LSS were confirmed clinically and on imaging.

OUTCOME MEASURES

Self-reported measures were food record, Short-Form 36 (SF-36), pain scales, Swiss Spinal Stenosis Symptom and Physical Function Scales, Oswestry Disability Index (ODI), Pain Catastrophizing Questionnaire, Tampa Scale for Kinesiophobia, Center for Epidemiologic Studies(Depression) Scale, Behavioral Regular in Exercise Questionnaire, and Regulation for Eating Behavior Scale and physiologic measures were dual-energy X-ray absorptiometry (DXA), blood draw, 7-day accelerometry, self-paced walking test, and balance test.

METHODS

The e-health platform was developed.

INTERVENTION

during Week 1, participants received a pedometer and a personalized consultation with a dietitian and an exercise physiologist. For 12 weeks, participants logged on to the e-health Web site to access personal step goals, nutrition education videos, and a discussion board. Follow-up occurred at Week 13.

RESULTS

Nine participants had a mean age of 67.5±6.7 years (60% women). Significant improvements were observed for fat mass (DXA), trunk fat mass, symptom severity (Swiss Symptom Scale), energy intake, maximum continuous activity (accelerometry), and mental health (SF-36) (p<.05). Nonsignificant improvements were observed for waist circumference, pain, ODI, and obesity biomarkers. Seventy percent lost weight, 50% increased walking capacity, and 60% increased quality of life. The mean increase in steps was 15%.

CONCLUSIONS

The spinal stenosis pedometer and nutrition lifestyle intervention was shown to be feasible, attractive to participants, and effective in this small sample. This intervention provides people with LSS the opportunity to participate in their own health management, potentially improving access to care. Efficacy is currently being assessed in a randomized trial.

Amantadine Effect on Perceptions of Irritability after Traumatic Brain Injury: Results of the Amantadine Irritability Multisite Study

This study examines the effect of amantadine on irritability in persons in the post-acute period after traumatic brain injury (TBI). There were 168 persons ≥6 months post-TBI with irritability who were enrolled in a parallel-group, randomized, double-blind, placebo-controlled trial receiving either amantadine 100 mg twice daily or equivalent placebo for 60 days. Subjects were assessed at baseline and days 28 (primary end-point) and 60 of treatment using observer-rated and participant-rated Neuropsychiatric Inventory (NPI-I) Most Problematic item (primary outcome), NPI Most Aberrant item, and NPI-I Distress Scores, as well as physician-rated Clinical Global Impressions (CGI) scale. Observer ratings between the two groups were not statistically significantly different at day 28 or 60; however, observers rated the majority in both groups as having improved at both intervals. Participant ratings for day 60 demonstrated improvements in both groups with greater improvement in the amantadine group on NPI-I Most Problematic (p<0.04) and NPI-I Distress (p<0.04). These results were not significant with correction for multiple comparisons. CGI demonstrated greater improvement for amantadine than the placebo group (p<0.04). Adverse event occurrence did not differ between the two groups. While observers in both groups reported large improvements, significant group differences were not found for the primary outcome (observer ratings) at either day 28 or 60. This large placebo or nonspecific effect may have masked detection of a treatment effect. The result of this study of amantadine 100 mg every morning and noon to reduce irritability was not positive from the observer perspective, although there are indications of improvement at day 60 from the perspective of persons with TBI and clinicians that may warrant further investigation.

Integrating mobile technology with routine dietetic practice: the case of myPace for weight management

The field of Mobile health (mHealth), which includes mobile phone applications (apps), is growing rapidly and has the potential to transform healthcare by increasing its quality and efficiency. The present paper focuses particularly on mobile technology for body weight management, including mobile phone apps for weight loss and the available evidence on their effectiveness. Translation of behaviour change theory into weight management strategies, including integration in mobile technology is also discussed. Moreover, the paper presents and discusses the myPace platform as a case in point. There is little clinical evidence on the effectiveness of currently available mobile phone apps in enabling behaviour change and improving health-related outcomes, including sustained body weight loss. Moreover, it is unclear to what extent these apps have been developed in collaboration with health professionals, such as dietitians, and the extent to which apps draw on and operationalise behaviour change techniques has not been explored. Furthermore, presently weight management apps are not built for use as part of dietetic practice, or indeed healthcare more widely, where face-to-face engagement is fundamental for instituting the building blocks for sustained lifestyle change. myPace is an innovative mobile technology for weight management meant to be embedded into and to enhance dietetic practice. Developed out of systematic, iterative stages of engagement with dietitians and consumers, it is uniquely designed to complement and support the trusted health practitioner–patient relationship. Future mHealth technology would benefit if engagement with health professionals and/or targeted patient groups, and behaviour change theory stood as the basis for technology development. Particularly, integrating technology into routine health care practice, rather than replacing one with the other, could be the way forward.

Use of electronic dietary assessment tools in primary care: an interdisciplinary perspective

BACKGROUND

Dietary assessment can be challenging for many reasons, including the wide variety of foods, eating patterns and nutrients to be considered. In team-based primary care practice, various disciplines may be involved in assessing diet. Electronic-based dietary assessment (e-DA) instruments available now through mobile apps or websites can potentially facilitate dietary assessment. Providers views of facilitators and barriers related to e-DA instruments and their recommendations for improvement can inform the further development of these tools. The objective of this study was to explore provider perspectives on e-DA tools in mobile apps and websites.

METHODS

The exploratory sequential mixed methods design included interdisciplinary focus groups followed by a web-based survey sent to Family Health Teams throughout Ontario, Canada. Descriptive and bivariate analyses were completed. Focus group transcripts contributed to web-survey content, while interpretive themes added depth and context.

RESULTS

11 focus groups with 50 providers revealed varying perspectives on the use of e-DA for: 1) improving patients' eating habits; 2) improving the quality of dietary assessment; and, 3) integrating e-DA into the care process. In the web-survey 191 respondents from nine disciplines in 73 FHTs completed the survey. Dietitians reported greater use of e-DA than other providers (63% vs.19%; p = .000) respectively. There was strong interest among disciplines in the use of e-DA tools for the management of obesity, diabetes and heart disease, especially for patient self-monitoring. Barriers identified were: patients' lack of comfort with using technology, misinterpretation of e-DA results by patients, time and education for providers to interpret results, and time for providers to offer counselling.

CONCLUSIONS

e-DA tools in mobile apps and websites may improve dietary counselling over time. Addressing the identified facilitators and barriers can potentially promote the uptake of e-DA into clinical practice.

Structured hypocaloric diet is more effective than behavioral therapy in reducing metabolic syndrome in Mexican postmenopausal women: a randomized controlled trial

OBJECTIVE

This study aims to compare the effects of a lifestyle intervention using a behavioral therapy (BT) approach with the effects of a cardioprotective structured hypocaloric diet on metabolic syndrome in Mexican postmenopausal women.

METHODS

This study is a randomized clinical trial (2006-2009) of Mexican postmenopausal women with metabolic syndrome (Adult Treatment Panel III criteria) who were recruited from the Postmenopause Clinic of the National Institute of Perinatology in Mexico City. Women were assigned to one of two groups--group 1 (structured hypocaloric diet; n = 63): energy restriction (-300 to -500 kcal/d) emphasizing cardioprotective dietary changes; and group 2 (BT; n = 55): goal setting, problem-solving, and stimulus control to achieve cardioprotective dietary and lifestyle recommendations. Metabolic syndrome prevalence, as well as weight, waist circumference, fat mass, and fasting biochemical markers (glucose and lipid profile), were measured at baseline and at 2, 4, and 6 months after the intervention. Metabolic syndrome risk (relative risk and absolute risk reduction), mean differences between groups, and logistic regression were evaluated using Statistical Package for the Social Sciences software, version 17.0.

RESULTS

A total of 118 women were studied (mean [SD] age, 53.81 [6.43] y). No baseline differences were observed between groups. At the end of the study, a higher reduction in metabolic syndrome prevalence was observed in group 1 (-38.1%) compared with group 2 (-12.7%; relative risk, 0.237; 95% CI, 0.092-0.608; P = 0.003). The effect was maintained even when adjusted by age, hormone therapy and antihypertensive drug use.

CONCLUSIONS

A cardioprotective structured hypocaloric diet is more effective than the BT approach in reducing metabolic syndrome after 6 months of intervention. Both strategies have positive effects on different individual cardiovascular risk factors.

Comparison of standardized patients and real patients as an experiential teaching strategy in a nutrition counseling course for dietetic students

OBJECTIVES

To compare the quality of communication and behavioral change skills among dietetic students having two nutrition encounters with either a real patient or a standardized patient in the simulation laboratory at Drexel University, Philadelphia, PA, United States.

METHODS

A retrospective analysis of video recordings (n=138) containing nutrition encounters of dietetic students (n=75) meeting with a standardized patient (SP) or a real patient (RP). Trained raters evaluated communication skills with the 28 item Calgary Cambridge Observation Guide (CCOG) and skills promoting behavior change using the 11 item Behavior Change Counseling Index (BECCI) tool.

RESULTS

Using the CCOG, there was a significantly greater mean score in the SP group for the category of "Gathering Information" in encounter one (p=0.020). There were good to excellent ratings in all categories of the CCOG and the BECCI scores for the SP and the RP groups at both encounters. There was no significant differences in change scores from encounter one to encounter two between groups.

CONCLUSIONS

Encounters with SPs and RPs are both effective strategies for dietetic students to demonstrate their communication and behavior change skills.

PRACTICE IMPLICATIONS

Utilizing SPs is an effective experiential strategy for nutrition counseling curricula.

Nutrition knowledge, diet quality and hypertension in a working population

OBJECTIVE

To examine if employees with higher nutrition knowledge have better diet quality and lower prevalence of hypertension.

METHOD

Cross-sectional baseline data were obtained from the complex workplace dietary intervention trial, the Food Choice at Work Study. Participants included 828 randomly selected employees (18-64 years) recruited from four multinational manufacturing workplaces in Ireland, 2013. A validated questionnaire assessed nutrition knowledge. Food Frequency Questionnaires (FFQ) measured diet quality from which a DASH (Dietary Approaches to Stop Hypertension) score was constructed. Standardised digital blood pressure monitors measured hypertension.

RESULTS

Nutrition knowledge was positively associated with diet quality after adjustment for age, gender, health status, lifestyle and socio-demographic characteristics. The odds of having a high DASH score (better diet quality) were 6 times higher in the highest nutrition knowledge group compared to the lowest group (OR = 5.8, 95% CI 3.5 to 9.6). Employees in the highest nutrition knowledge group were 60% less likely to be hypertensive compared to the lowest group (OR = 0.4, 95% CI 0.2 to 0.87). However, multivariate analyses were not consistent with a mediation effect of the DASH score on the association between nutrition knowledge and blood pressure.

CONCLUSION

Higher nutrition knowledge is associated with better diet quality and lower blood pressure but the inter-relationships between these variables are complex.

Changing dietary behaviour: the role and development of practitioner communication

The need to support people to change diet-related behaviour is widely advocated and how to do this effectively in practice is an expanding area of research. Important factors to consider are how healthcare practitioners communicate with their patients and how that communication may affect diet-related behaviour change and subsequent outcomes. The aim of the present paper is to discuss communication skills for behaviour change (CSBC), focusing predominantly on registered dietitians who are required to communicate effectively and have an important role in supporting patients to change diet-related behaviour. The views of dietitians in relation to CSBC have been investigated and respondents have consistently reported that they perceive these skills to be of vital importance in practice. Patient views have reiterated the importance of good CSBC in one-to-one consultations. However, pre-qualification training of dietitians is thought to deliver practitioners who are competent at a minimum level. The need for ongoing continuous professional development (CPD) in relation to CSBC has been recognised but currently most CPD focuses on updating knowledge rather than improving these essential skills. Measuring CSBC in a consistent and objective manner is difficult and an assessment tool, DIET-COMMS, has been developed and validated for this purpose. DIET-COMMS can be used to support CSBC development, but concerns about logistical challenges and acceptability of implementing this in practice have been raised. Although a suitable assessment tool now exists there is a need to develop ways to facilitate assessment of CSBC in practice.

Candy consumption patterns, effects on health, and behavioral strategies to promote moderation: summary report of a roundtable discussion

Nearly all Americans (97%) report eating candy at least once per year; yet, on a given day, only approximately one-fourth of the US population aged ≥2 y consumes candy. Among all Americans, candy contributes a relatively small proportion of calories, added sugars, and saturated fat to the total diet, and recent research suggests that current levels of candy consumption are not associated with risk of weight gain and cardiovascular disease in children and adults. Providing guidance for the consumption of candy in moderation requires an understanding of various behavioral health-related factors that influence candy consumption. A roundtable of behavioral nutrition experts, researchers, and nutrition educators met to discuss recent data on intakes of candy, health outcomes associated with usual candy intake, and the impact of behavioral strategies, including restriction, education, and environmental awareness, on modifying eating behaviors to achieve moderate intakes of candy. Restricting access to palatable foods, whether self-imposed or by parental control, may have potentially negative consequences. Techniques and insight into how to adopt "moderation" in candy consumption, from effective parental practices to environmental strategies that facilitate behavior change without a high degree of effort, were identified as important next steps toward sustainable dietary guidance related to the role of candy and other treats in a healthy lifestyle.

Best nutrition counseling practices for the treatment of anorexia nervosa: a Delphi study

OBJECTIVE

To use Delphi methodology to evaluate the extent to which a panel of registered dietitians (RDs) who treat anorexia nervosa (AN) concur on parameters related to nutrition counseling for AN.

METHOD

The twenty-one panelists who participated in this study: (i) were RDs (ii) had specialized in nutritional counseling for eating disorders for 5 years or more, and (iii) had Internet access at home or work. Over a 10-week period (between 8/2013 and 11/2013), panelists completed three iterative questionnaires. Questionnaire 1 included 12 open-ended questions regarding nutrition counseling for patients with AN. Subsequent questionnaires were developed based on a content analysis of responses to the first questionnaire, and panelists were asked to rank their level of agreement with these items.

RESULTS

Consensus was defined as 85% agreement and was achieved for 47 (35.3%) of the 133 items included in the third questionnaire. Items achieving consensus described nutrition counseling approaches that are applicable to all patients with AN, and their wording typically allowed for consideration of individual needs. Some items that did not achieve consensus reflected approaches for which individual tailoring may be necessary depending on age, stage of illness, and other patient factors. Consensus was also not shown for approaches for which there is little evidence.

DISCUSSION

Nutritional counseling intervention for AN has some consensus features, but the need for individualization was apparent. A stronger evidence-base for nutritional counseling interventions for AN would provide guidance and facilitate greater consistency among RDs regarding how to best care for this patient population.

Metering Self-Reported Adherence to Clinical Outcomes in Malaysian Patients With Hypertension: Applying the Stages of Change Model to Healthful Behaviors in the CORFIS Study

The CORFIS (Community-Based Cardiovascular Risk Factors Intervention Strategies) program was piloted in community clinics in Malaysia to address the lack of health education in chronic disease management. The stages of change model was applied in a multicenter quasi-experimental design to evaluate adherence to advocated behaviors in CORFIS patients with hypertension. Based on submitted diet and exercise records (n = 209), adherence to sodium reduction, regular exercise, and increasing fruit and vegetable intake behaviors were quantified against weight, waist circumference (WC), systolic blood pressure (SBP), and diastolic blood pressure (DBP) changes. Patients were categorized at 6 months into nonadherent/N-A (Precontemplation, Contemplation, and Preparation), newly adherent/NA (Action) and totally adherent/TA (Maintenance) groups. Self-reported adherence records did not meet recommended targets for healthful behaviors, but clinical benefits were achieved by adherent groups as indicated by effect size (Cohen's d) comparisons. SBP reduction was associated with adherence to sodium reduction in NA (d = 0.60, p < .001) and TA (d = 0.45, p < .001) compared to N-A (d = 0.13, p > .05). Marginally increasing fruit and vegetable consumption (Δ = 0.41 servings) resulted in sizeable reductions in weight for NA (d = 0.81, p < .001) > TA (d = 0.54, p < .001) > N-A (d = 0.21, p > .05) and in WC for NA (d = 0.68, p < .00) > TA (d = 0.53, p < .001) > N-A (d = 0.52, p > .05). Exercise behavior was least successful as pedometer counting was below 10,000 steps but sizeable weight and WC reductions were largest for NA (d = 0.71 and 0.79, respectively) > TA (d = 0.60 and 0.53, respectively) > N-A (d = 0.33 and 0.35, respectively). Patients reporting a shift to positive stages of change behaviors enjoyed clinically beneficial reductions in SBP, DBP, weight, and WC.

Nutrition Controversies

Nutrition controversies abound, particularly in an age of vast information and technology. Scientific information is often disseminated so quickly, via news outlets or lay bloggers, that the factual details are left out and in-depth analysis is omitted. Our food supply and our environment are intertwined, yet from a public health standpoint there seems to be a disconnection between what our society wants, and what it may need, in terms of nutrition and disease prevention. We want our food supply to be safe, available, affordable, fresh, and tasty. We also want our environment to be minimally affected, animal rights to be upheld, and less waste to occur. We need to provide adequate nutrition that promotes health to a diverse population at a reasonable cost. This article will address some current nutrition controversies surrounding genetically modified organisms in our food supply, sugars, calories, and high-protein diets; as well as a recommendation for helping your patients choose a healthy diet and adopt healthy dietary behaviors is reviewed.

Nutritional Counseling in Survivors of Childhood Cancer: An Essential Component of Survivorship Care

There is a growing body of evidence suggesting that nutritional status during treatment for cancer has a significant impact on treatment-related toxicities and outcomes among children and adolescents with cancer. The effects of nutritional status appear to extend into survivorship with a large proportion of survivors at risk for a variety of nutrition-related morbidities. The influence of dietary intake on overall treatment outcomes and long-term morbidities is largely unknown. In adults, evidence suggests that greater adherence to cancer prevention dietary guidelines improves long-term health outcomes among survivors of cancer. Surveys describing dietary intake among survivors of childhood cancer have found that most survivors are not meeting the recommended guidelines for many dietary nutrients and this may have an unfavorable effect on nutrition-related outcomes. However, more research is needed in this area so that well-designed clinical trials may be developed and tested. This review presents an overview of the existing literature describing dietary intake among survivors of childhood cancer, the clinical implications of reported dietary behaviors among survivors, and identifies areas for future research.

Developing and testing a measurement tool for assessing predictors of breakfast consumption based on a health promotion model

OBJECTIVE

To develop an instrument for measuring Health Promotion Model constructs in terms of breakfast consumption, and to identify the constructs that were predictors of breakfast consumption among Iranian female students.

DESIGN

A questionnaire on Health Promotion Model variables was developed and potential predictors of breakfast consumption were assessed using this tool.

PARTICIPANTS

One hundred female students, mean age 13 years (SD ± 1.2 years).

SETTINGS

Two middle schools from moderate-income areas in Qom, Iran.

VARIABLES MEASURED

Health Promotion Model variables were assessed using a 58-item questionnaire. Breakfast consumption was also measured.

ANALYSIS

Internal consistency (Cronbach alpha), content validity index, content validity ratio, multiple linear regression using stepwise method, and Pearson correlation.

RESULTS

Content validity index and content validity ratio scores of the developed scale items were 0.89 and 0.93, respectively. Internal consistencies (range, .74-.91) of subscales were acceptable. Prior related behaviors, perceived barriers, self-efficacy, and competing demand and preferences were 4 constructs that could predict 63% variance of breakfast frequency per week among subjects.

CONCLUSIONS AND IMPLICATIONS

The instrument developed in this study may be a useful tool for researchers to explore factors affecting breakfast consumption among students. Students with a high level of self-efficacy, more prior related behavior, fewer perceived barriers, and fewer competing demands were most likely to regularly consume breakfast.

Weight Loss Intervention in Survivors of ER/PR-negative Breast Cancer

Numerous studies have found that increased body size (weight or body mass index) is a risk factor for breast cancer development, recurrence, and death. The detrimental relationship between body size and breast cancer recurrence may be more pronounced among women with estrogen receptor (ER)/progesterone receptor (PR)-negative breast cancer. Considering the limited availability of treatments, and the association between body size and recurrence, alternative treatments are needed for ER/PR-negative breast cancer survivors, particularly overweight survivors. The objective of this pilot study was to examine the feasibility of a 12-week, multi-component meal-replacement weight loss intervention among overweight or obese ER/PR-negative breast cancer survivors; and to obtain preliminary data on changes in anthropometrics, biomarkers, and health-related quality of life (QOL). The 12-week intervention included a portion-controlled diet (including meal replacements) and a multi-component intervention (including behavioral techniques, diet modification, physical activity, and social support). The goal of the intervention was to help participants lose 5% or more of their initial weight by reducing their caloric intake and increasing their physical activity (to at least 15 minutes each day). Paired t-tests assessed changes in continuous measures. Body weight was measured weekly and mixed-model regression analysis assessed change in weight over time. Nineteen ER/PR-negative breast cancer survivors with a mean age of 59 years participated in the study. All but two of the participants completed the 12-week intervention. Women lost an average of 6.3 ± 4.9 kg (P < 0.001), equivalent to 7.5% of their baseline weight. There were significant reductions in waist circumference (P = 0.001), percent fat mass (P < 0.001), total cholesterol (P = 0.026), and triglycerides (P = 0.002); and improvements in health-related QOL (P = 0.017). Findings suggested that a meal-replacement weight loss approach among ER/PR-negative breast cancer survivors was feasible and was well received.

An adaptation of family-based behavioral pediatric obesity treatment for a primary care setting: group health family wellness program pilot

OBJECTIVE

To assess the feasibility and acceptability of family-based group pediatric obesity treatment in a primary care setting, to obtain an estimate of its effectiveness, and to describe participating parents' experiences of social support for healthy lifestyle changes.

METHODS

We adapted an evidence-based intervention to a group format and completed six 12- to 16-week groups over 3 years. We assessed program attendance and completion, changes in child and parent body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and changes in child quality of life in a single-arm before-and-after trial. Qualitative interviews explored social support for implementing healthy lifestyle changes.

RESULTS

Thirty-eight parent-child pairs enrolled (28% of the 134 pairs invited). Of those, 24 (63%) completed the program and another 6 (16%) attended at least 4 sessions but did not complete the program. Children who completed the program achieved a mean change in BMI Z-scores (Z-BMI) of -0.1 (0.1) (p < 0.001) and significant improvement in parent-reported child quality of life (mean change = 8.5; p = 0.002). Mean BMI of parents changed by -0.9 (p = 0.003). Parents reported receiving a wide range of social support for healthy lifestyle changes and placed importance on the absence or presence of support.

CONCLUSIONS

A pilot group program for family-based treatment of pediatric obesity is feasible and acceptable in a primary care setting. Change in child and parent BMI outcomes and child quality of life among completers were promising despite the pilot's low intensity. Parent experiences with lack of social support suggest possible ways to improve retention and adherence.

The 3-year evolution of a preschool physical activity intervention through a collaborative partnership between research interventionists and preschool teachers

Despite evidence that preschoolers spend the majority of their time in sedentary activities, few physical activity interventions have focused on preschool-age children. Health promotion interventions that can be integrated into the daily routines of a school or other setting are more likely to be implemented. The Study of Health and Activity in Preschool Environments employed a flexible approach to increasing physical activity opportunities in preschools' daily schedules through recess, indoor physical activity and physical activity integrated into academic lessons. Eight preschools were randomly assigned to receive the study's physical activity intervention. Teachers in these schools partnered with university-based interventionists across 3 years to design and implement a flexible and adaptive intervention. The intervention approach included trainings and workshops, site visits and feedback from intervention personnel, newsletters, and physical activity equipment and materials. Teachers reported a high acceptability of the intervention. The purpose of this article is to describe the evolution of a multi-component physical activity intervention in preschools, including (i) a description of the intervention components, (ii) an explanation of the intervention process and approach, and (iii) a report of teachers' perceptions of barriers to implementation.

Key enablers to facilitate healthy behavior change: workshop summary

The increases in preventable chronic diseases and the rising costs of health care are unsustainable. The US Army Surgeon General's vision to transition from a health care system to a system of health requires the identification of key health enablers to facilitate the adoption of healthy behaviors. In support of this vision, the US Army Telemedicine and Advanced Technology Research Center hosted a workshop in April 2013 titled "Incentives to Create and Sustain Change for Health." Members of government and academia participated to identify key health enablers that could ultimately be leveraged by technology. The key health enablers discussed included (1) public health messaging, (2) changing health habits and the environmental influence on health, (3) goal setting and tracking, (4) the role of incentives in behavior-change intervention, and (5) the role of peer and social networks on change. This report summarizes leading evidence and the group consensus on evidence-based practices with respect to the key enablers in creating healthy behavior change.

Text messaging as adjunct to community-based weight management program

Increasing obesity rates are still a public health priority. The primary aim of this study was to evaluate the effect of tailored text messages on body weight change in overweight and obese adults in a community-based weight management program. A secondary aim was to detect behavioral changes in the same population. The study design was quasi-experimental with pretest and posttest analysis, conducted over 12 weeks. A total of 28 participants were included in the analysis. Body weight, eating behaviors, exercise and nutrition self-efficacy, attitude toward mobile technology, social support, and physical activity were assessed at baseline and at 12 weeks. Text messages were sent biweekly to the intervention but not to the control group. At 12 weeks, the intervention group had lost significant weight as compared with the control group. There was a trend toward an improvement in eating behaviors, exercise, and nutrition self-efficacy in the intervention group, with no significant difference between groups. A total of 79% of participants stated that text messages helped in adopting healthy behaviors. Tailored text messages appear to enhance weight loss in a weight management program at a community setting. Large-scale and long-term intervention studies are needed to confirm these findings.

Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: Community-Based Intergenerational Oral Health Study "Baby Smiles"

BACKGROUND

Fidelity assessments are integral to intervention research but few published trials report these processes in detail. We included plans for fidelity monitoring in the design of a community-based intervention trial.

METHODS

The study design was a randomized clinical trial of an intervention provided to low-income women to increase utilization of dental care during pregnancy (mother) or the postpartum (child) period. Group assignment followed a 2 × 2 factorial design in which participants were randomly assigned to receive either brief Motivational Interviewing (MI) or Health Education (HE) during pregnancy (prenatal) and then randomly reassigned to one of these groups for the postpartum intervention. The study setting was four county health departments in rural Oregon State, USA. Counseling was standardized using a step-by-step manual. Counselors were trained to criteria prior to delivering the intervention and fidelity monitoring continued throughout the implementation period based on audio recordings of counselor-participant sessions. The Yale Adherence and Competence Scale (YACS), modified for this study, was used to code the audio recordings of the counselors' delivery of both the MI and HE interventions. Using Interclass Correlation Coefficients totaling the occurrences of specific MI counseling behaviors, ICC for prenatal was .93, for postpartum the ICC was .75. Participants provided a second source of fidelity data. As a second source of fidelity data, the participants completed the Feedback Questionnaire that included ratings of their satisfaction with the counselors at the completion of the prenatal and post-partum interventions.

RESULTS

Coding indicated counselor adherence to MI protocol and variation among counselors in the use of MI skills in the MI condition. Almost no MI behaviors were found in the HE condition. Differences in the length of time to deliver intervention were found; as expected, the HE intervention took less time. There were no differences between the overall participants' satisfaction ratings of the HE and MI sessions by individual counselor or overall (p > .05).

CONCLUSIONS

Trial design, protocol specification, training, and continuous supervision led to a high degree of treatment fidelity for the counseling interventions in this randomized clinical trial and will increase confidence in the interpretation of the trial findings.

Unconscious agendas in the etiology of refractory obesity and the role of hypnosis in their identification and resolution: a new paradigm for weight-management programs or a paradigm revisited?

Hypnosis has long been recognized as an effective tool for producing behavioral change in the eating disorders anorexia and bulimia. Despite many studies from the latter half of the last century suggesting that hypnosis might also be of value in managing obesity situations, the efficacy of hypnotherapy for weight reduction has received surprisingly little formal research attention since 2000. This review presents a brief history of early clinical studies using hypnosis for weight reduction and describes a hypnotherapeutic approach within which a combination of instructional/pedagogic and exploratory therapeutic sessions can work together synergistically to maximize the potential for sustained weight loss. Hypnotic modulation of appetite- and satiation-associated peptides and hormone levels may yield additional physiological benefits in Type 1 and Type 2 diabetes.

SisterTalk: final results of a culturally tailored cable television delivered weight control program for Black women

BACKGROUND

Obesity among Black women continues to exceed that of other women. Most weight loss programs created without reference to specific cultural contexts are less effective for Black than White women. Weight control approaches accessible to Black women and adapted to relevant cultural contexts are important for addressing this problem. This paper reports the final results of SisterTalk, the randomized controlled trial of a cable TV weight control program oriented toward Black women.

METHODS

A five group design included a comparison group and a 2 × 2 factorial comparison of a) interactive vs. passive programming and b) telephone social support vs no telephone support, with 12 weekly initial cable TV programs followed by 4 monthly booster videos. At baseline, 3, 8, and 12 months post randomization, telephone and in person surveys were administered on diet, physical activity, and physical measurements of height and weight were taken to calculate body mass index (BMI). Analysis of variance (ANOVA) was used to examine differences over time, and between treatment and comparison groups. Dose variables reflecting use of the TV/video and written materials were also assessed.

RESULTS

At 3 months, BMI, weight, and dietary fat were significantly lower and physical activity significantly higher among women exposed to the Cable TV intervention compared to the wait-list comparison group. Significant dietary fat differences were still observed at 8 and 12 month evaluations, but not BMI or physical activity differences. Main effects were not observed for interactive programming or enhanced social support at any time point. Within the intervention group, higher watching of the TV series and higher reading of educational materials were both (separately) associated with significantly lower dietary fat.

CONCLUSIONS

Cable TV was an effective delivery channel to assist Black women with weight control, increasing physical activity and decreasing dietary fat during an initial intervention period, but only dietary changes persisted Enhanced social support and the ability to interact with others during the show were not effective complementary intervention components as conducted in this trial. Future research to strengthen the ability of this approach to achieve long term effects may offer even more promising outcomes.

Pregnancy

Pregnancy is a time when women are at increased risk to gain substantial weight. It is also a time when women are more health conscious and may be more likely to engage in healthier behaviors. Because of these factors, women are primed to engage in lifestyle strategies to promote healthy weight gain during pregnancy. Similarly, mothers of newborns also have an increased readiness for change, making infancy an ideal time to begin obesity prevention efforts in families. Health care providers are encouraged to take advantage of the increased health awareness and the behavioral momentum that is present surrounding pregnancy in order to promote healthy lifestyle changes for both pregnant women and new mothers.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI) randomized controlled trial protocol

BACKGROUND

Because of symptoms, people with lumbar spinal stenosis (LSS) are often inactive, and this sedentary behaviour implies risk for diseases including obesity. Research has identified body mass index as the most powerful predictor of function in LSS. This suggests that function may be improved by targeting weight as a modifiable factor. An e-health lifestyle intervention was developed aimed at reducing fat mass and increasing physical activity in people with LSS. The main components of this intervention include pedometer-based physical activity promotion and nutrition education.

METHODS/DESIGN

The Spinal Stenosis Pedometer and Nutrition Lifestyle INTERVENTION (SSPANLI) was developed and piloted with 10 individuals. The protocol for a randomized controlled trail comparing the SSPANLI intervention to usual non-surgical care follows. One hundred six (106) overweight or obese individuals with LSS will be recruited. Baseline and follow-up testing includes dual energy x-ray absorptiometry, blood draw, 3-day food record, 7-day accelerometry, questionnaire, maximal oxygen consumption, neurological exam, balance testing and a Self-Paced Walking Test.

INTERVENTION

During Week 1, the intervention group will receive a pedometer, and a personalized consultation with both a Dietitian and an exercise specialist. For 12 weeks participants will log on to the e-health website to access personal step goals, walking maps, nutrition videos, and motivational quotes. Participants will also have access to in-person Coffee Talk meetings every 3 weeks, and meet with the Dietitian and exercise specialist at week 6. The control group will proceed with usual care for the 12-week period. Follow-up testing will occur at Weeks 13 and 24.

DISCUSSION

This lifestyle intervention has the potential to provide a unique, non-surgical management option for people with LSS. Through decreased fat mass and increased function, we may reduce risk for obesity, chronic diseases of inactivity, and pain. The use of e-health interventions provides an opportunity for patients to become more involved in managing their own health. Behaviour changes including increased physical activity, and improved dietary habits promote overall health and quality of life, and may decrease future health care needs in this population.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01902979.

Nutrition therapy recommendations for the management of adults with diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

Reward-based, task-setting education strategy on glycemic control and self-management for low-income outpatients with type 2 diabetes

AIMS/INTRODUCTION

The purpose of the study was to determine the feasibility and effect of a reward-based, task-setting strategy for low-income outpatients with type 2 diabetes.

MATERIALS AND METHODS

Indigent diabetes outpatients without glucometers were eligible to participate in this trial. A total of 132 cases were randomly recruited. Participants in group B used glucometers for self-monitoring at no cost. Group A participants could keep the glucometers only if the glycosylated hemoglobin level declined compared with the baseline visit; for those not achieving a reduction in the glycosylated hemoglobin level, the glucometers would have to be returned. Group C served as the control group without self-monitoring setout. Diabetes education was provided to all groups. Metabolic indices and self-management were evaluated after 6 months of follow up.

RESULTS

Group A had a significant decline in the glycosylated hemoglobin level (-0.97%) and medical costs (-159 yuan) compared with the baseline visit, whereas groups B and C had a decrease in the glycosylated hemoglobin levels alone (-0.62 and -0.57%, respectively). The body mass index did not change significantly in any group. There was a statistical difference in the glycosylated hemoglobin level of group A compared with groups B and C. Self-management in group A improved the outcome relative to groups B and C.

CONCLUSIONS

This preliminary evidence suggests that the program is feasible, acceptable for improving patient self-management, and cost-effective in reducing the glycosylated hemoglobin level and medical costs.

Nutritional management of insulin resistance in nonalcoholic fatty liver disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is an emerging global health concern. It is the most common form of chronic liver disease in Western countries, affecting both adults and children. NAFLD encompasses a broad spectrum of fatty liver disease, ranging from simple steatosis (NAFL) to nonalcoholic steatohepatitis (NASH), and is strongly associated with obesity, insulin resistance, and dyslipidemia. First-line therapy for NAFLD includes weight loss achieved through diet and physical activity. However, there is a lack of evidenced-based dietary recommendations. The American Diabetes Association's (ADA) recommendations that aim to reduce the risk of diabetes and cardiovascular disease may also be applicable to the NAFLD population. The objectives of this review are to: (1) provide an overview of NAFLD in the context of insulin resistance, and (2) provide a rationale for applying relevant aspects of the ADA recommendations to the nutritional management of NAFLD.

What do the terms wellness and wellbeing mean in dietary practice: an exploratory qualitative study examining women's perceptions

BACKGROUND

Wellness and wellbeing are terms associated with health within dietetic discourse. More broadly, these terms are found in social discourse as represented in food and nutrition consumer communications. With the increasing requirement for evidence-based healthcare, there is an imperative to understand whether these terms are meaningful to individuals typically targeted for nutrition interventions and whether there are any implications for dietetic education.

METHODS

To explore the understanding of these terms, eight semi-structured focus groups were conducted with 32 female participants (age range 23-79 years) who were actively engaged in managing their health. Overall understanding of the terms, factors that impacted perceptions and any relationships with food behaviour were investigated with the groups. Group discussions were transcribed verbatim and each transcript was examined by two researchers. Inductive analysis linking codes into main thematic categories was conducted using the constant comparison approach across the full data set.

RESULTS

Wellness and wellbeing were identified as meaningful terms associated with health. A theoretical framework of wellness and wellbeing reflecting these meanings was developed linking four dominant thematic areas. These were Desired outcomes (most sought after result); Taking control (self management strategies); Internal influences (various personal inner factors influencing behaviours); and External influences (plethora of peripheral factors influencing behaviours).

CONCLUSIONS

Wellness and wellbeing are terms that are relevant and aspirational for individuals typically targeted for nutrition intervention. A theoretical framework of dominant areas of influence on notions of wellness and wellbeing was identified. This theoretical framework is worthy of further research to determine usefulness and effectiveness in dietetic practice settings.

A randomized clinical trial comparing delivery of behavioral pediatric obesity treatment using standard and enhanced motivational approaches

OBJECTIVE

To examine the efficacy of an adjunct motivational and autonomy-enhancing intervention (self-directed) for behavioral family-based pediatric obesity relative to the standard prescription of uniform behavioral skills use and interventionist goal assignment (prescribed).

METHODS

In this randomized clinical trial, 72 overweight/obese children and their parents/caregivers were assigned to either self-directed or prescribed intervention for 20 weeks, with approaches diverging after week 5. Anthropometric measurements from child and participating parent at baseline, posttreatment, and 3-month, 6-month, 1-year, and 2-year follow-ups were evaluated for change (n = 59 in follow-up analyses).

RESULTS

The approaches demonstrated similar child body mass index (BMI) z-score and parent BMI change from baseline to posttreatment and throughout follow-up, with child and parent weight status lower than baseline at 2 years after treatment cessation.

CONCLUSIONS

An adjunct motivational and autonomy-enhancing approach to behavioral family-based pediatric obesity treatment is a viable alternative to the standard intervention approach.

The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods

Disseminating and implementing evidence-based, cardiovascular disease (CVD) prevention lifestyle interventions in community settings and in ethnic minority populations is a challenge. We describe the design and methods for the South Asian Heart Lifestyle Intervention (SAHELI) study, a pilot study designed to determine the feasibility and initial efficacy of a culturally-targeted, community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians (SAs). Participants with at least one CVD risk factor will be randomized to either a lifestyle intervention or a control group. Participants in both groups will be screened in a community setting and receive a primary care referral after randomization. Intervention participants will receive 6weeks of group classes, followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal. Control participants will receive their screening results and monthly mailings on CVD prevention. Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline, 3-, and 6-month follow-up. Secondary outcomes will be changes in weight, clinical risk factors, primary care visits, self-efficacy, and social support. This study will be one of the first to pilot-test a lifestyle intervention for SAs, one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk. Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population.

Providers' roles in enhancing patients' adherence to pain self management

Practice guidelines and empirical research related to pain management encourage clinicians to take active roles in providing education about self management and promoting adoption of a self-management approach. The purpose of the study was to review the relevant literature, summarize aspects of the patient-provider interaction that influence patient engagement in self management for chronic pain, and outline practice recommendations in this area. Review of the literature on aspects of the patient-provider interaction that promote engagement in pain self-management was used. Findings are synthesized into recommendations for providers. Patients benefit from a biopsychosocial and patient-centered approach. Patients are more likely to fully disclose when providers respond empathically, which can improve conceptualization and treatment. Patient education and motivation play important roles in engaging patients in self management. Self management is influenced in part by the patient-provider communication process. Suggestions for communication strategies to facilitate patient engagement in self-management techniques, including empathic discussion of barriers and motivation enhancement, are provided.

Dietary approaches to hypertension: a call to pharmacists to promote lifestyle changes

OBJECTIVES

To describe guideline updates regarding a dietary approach to preventing or treating hypertension and to encourage pharmacists to provide education to patients on the Dietary Approaches to Stop Hypertension (DASH) diet and reducing dietary sodium intake.

DATA SOURCES

Abstracts and published articles identified by searching Medline (January 2001 to July 2011) and International Pharmaceutical Abstracts (January 2001 to July 2011) using the terms hypertension, cardiovascular risk, risk reduction behavior, health behavior, community pharmacy services, counseling, diet, and sodium-restricted diet, as well as reports from the Institute of Medicine and Dietary Guidelines for Americans 2010.

DATA SYNTHESIS

In the Dietary Guidelines for Americans 2010, the recommended daily dietary sodium intakes for individuals with hypertension, chronic kidney disease, and diabetes was reduced to less than 1,500 mg per day. All other healthy individuals are recommended to achieve dietary sodium intakes of less than 2,300 mg per day. Americans are consuming excessive amounts of dietary sodium in the form of processed foods, which poses a barrier to blood pressure control. Pharmacists should recommend the DASH diet as a way to reduce intake of dietary sodium and use available nutrition resources found on the ChooseMyPlate.gov and Food and Drug Administration websites. Pharmacists should integrate approaches using behavioral and motivational strategies to provide education that is culturally sensitive and appeals to individuals with marginal health literacy.

CONCLUSION

Community and ambulatory practice pharmacists, as well as collaborative practice models between pharmacists and physicians, should optimize medication management and incorporate lifestyle interventions that reduce dietary sodium intake as part of a comprehensive approach to improve hypertension outcomes.

Motivational interviewing for patients with chronic kidney disease

Successful management of chronic kidney disease (CKD) typically involves consideration of several lifestyle changes and treatments that could improve patients' health outcomes. The complexity of behavioral changes and treatment decisions that must be made by patients, with the support of their treatment team, could diminish their motivation to address CKD and lead to poorer treatment outcomes. Hence, motivational enhancement, in the context of patient education and shared decision-making with the treatment team, is a critical issue in CKD patient care. This article describes how motivational interviewing can be used with patients to enhance their motivation to address CKD and participate in treatment.

Psychosocial factors associated with diet quality in a working adult population

The associations between specific intra- and inter-personal psychosocial factors and dietary patterns were explored in a healthy, working adult sample of university and health center employees (N = 640) who were enrolled in a prospective predictive health study. Participants had a mean age of 48 (SD = 11) years and were 67% women and 30% minority. Baseline psychosocial measures of perceived stress, depressive symptoms, social support, and family functioning were examined for their relationships with three diet quality indices-AHEI, DASH, and the Mediterranean. Dietary intake was of moderate quality in this high-income, well-educated, psychosocially healthy population. Social support was positively associated with better diet quality for all three indices (p < .01). Further research should focus on socio-environmental factors associated with diet quality.