Stage of Change for Healthful Eating and Use of Behavioral Strategies

Reducing cardiometabolic risk in adults with a low socioeconomic position: protocol of the Supreme Nudge parallel cluster-randomised controlled supermarket trial

Background

Unhealthy lifestyle behaviours such as unhealthy dietary intake and insufficient physical activity (PA) tend to cluster in adults with a low socioeconomic position (SEP), putting them at high cardiometabolic disease risk. Educational approaches aiming to improve lifestyle behaviours show limited effect in this population. Using environmental and context-specific interventions may create opportunities for sustainable behaviour change. In this study protocol, we describe the design of a real-life supermarket trial combining nudging, pricing and a mobile PA app with the aim to improve lifestyle behaviours and lower cardiometabolic disease risk in adults with a low SEP.

Methods

The Supreme Nudge trial includes nudging and pricing strategies cluster-randomised on the supermarket level, with: i) control group receiving no intervention; ii) group 1 receiving healthy food nudges (e.g., product placement or promotion); iii) group 2 receiving nudges and pricing strategies (taxing of unhealthy foods and subsidizing healthy foods). In collaboration with a Dutch supermarket chain we will select nine stores located in low SEP neighbourhoods, with the nearest competitor store at > 1 km distance and managed by a committed store manager. Across the clusters, a personalized mobile coaching app targeting walking behaviour will be randomised at the individual level, with: i) control group; ii) a group receiving the mobile PA app. All participants (target n = 1485) should be Dutch-speaking, aged 45–75 years with a low SEP and purchase more than half of their household grocery shopping at the selected supermarkets. Participants will be recruited via advertisements and mail-invitations followed by community-outreach methods. Primary outcomes are changes in systolic blood pressure, LDL-cholesterol, HbA1c and dietary intake after 12 months follow-up. Secondary outcomes are changes in diastolic blood pressure, blood lipid markers, waist circumference, steps per day, and behavioural factors including healthy food purchasing, food decision style, social cognitive factors related to nudges and to walking behaviours and customer satisfaction after 12 months follow-up. The trial will be reflexively monitored to support current and future implementation.

Discussion

The findings can guide future research and public health policies on reducing lifestyle-related health inequalities, and contribute to a supermarket-based health promotion intervention implementation roadmap.

Trial registration

Dutch Trial Register ID NL7064, 30th of May, 2018

Increasing the use of preventative health services to promote healthy eating, physical activity and weight management: the acceptability and potential effectiveness of a proactive telemarketing approach

BACKGROUND

Telephone based interventions are effective in promoting health behaviours. The use of telephone based support services to promote healthy eating, activity or weight loss, however, are currently under-utilised. The aim of this study was to assess the acceptability and potential effectiveness of a telemarketing approach in increasing community use of proactive services to encourage healthy eating, physical activity and weight loss.

METHODS

The study employed a cross sectional design. Eligible consenting participants completed a 15 minute telephone survey conducted by trained telephone interviewers using computer assisted telephone interviewing technology.

RESULTS

Overall, 87% of participants considered it acceptable for a health service to contact people by telephone to offer assistance to help them lose weight, eat healthily or be more physically active. Among participants with inadequate fruit and vegetable intake, physical activity or who were overweight, 64%, 54% and 61% respectively reported that they would use one or more of the proactive support services offered. Females and those from non -English speaking households who did not eat sufficient serves were significantly more likely to report that they would use support services.

CONCLUSIONS

The findings suggest that proactive telemarketing of health services to facilitate healthy eating, physical activity or weight loss is considered highly acceptable and may be effective in encouraging service use by more than half of all adults with these behavioural risks.

The transtheoretical model as applied to dietary behaviour and outcomes

The transtheoretical model (TTM) is a behavioural theory that describes behaviour change as occurring in five stages, ranging from precontemplation to maintenance. The purpose of the present paper is to review and synthesise the literature published since 1999 on applications of the TTM to dietary behaviour so that the evidence for the use of assessment tools and interventions based on this model might be evaluated. Six databases were identified and searched using combinations of key words. Sixty-five original, peer-reviewed studies were identified and summarised in one of three tables using the following categories: population (n 21), intervention (n 25) and validation (n 19). Internal validity ratings were given to each intervention, and the body of intervention studies as a whole was rated. The evidence for using stage-based interventions is rated as suggestive in the areas of fruit and vegetable consumption and dietary fat reduction. Valid and reliable staging algorithms are available for fruit and vegetable consumption and dietary fat intake, and are being developed for other dietary behaviours. Few assessment tools have been developed for other TTM constructs. Given the popularity of TTM-based assessments and interventions, more research is warranted to identify valid and reliable assessment tools and effective interventions. While the evidence supports the validity of the TTM to describe populations and to form interventions, evidence of the effectiveness of TTM-based interventions is not conclusive.

Reliability and validity of brief psychosocial measures related to dietary behaviors

Background

Measures of psychosocial constructs are required to assess dietary interventions. This study evaluated brief psychosocial scales related to 4 dietary behaviors (consumption of fat, fiber/whole grains, fruits, and vegetables).

Methods

Two studies were conducted. Study 1 assessed two-week reliability of the psychosocial measures with a sample of 49 college students. Study 2 assessed convergent and discriminant validity of the psychosocial measures with dietary nutrient estimates from a Food Frequency Questionnaire on 441 men and 401 women enrolled in an Internet-based weight loss intervention study.

Results

Study 1 test-retest reliability ICCs were strong and ranged from .63 to .79. In study 2, dietary fat cons, fiber/whole grain cons and self-efficacy, fruit and vegetable cons and self-efficacy, and healthy eating social support, environmental factors, enjoyment, and change strategies demonstrated adequate correlations with the corresponding dietary nutrient estimates.

Conclusions

Brief psychosocial measures related to dietary behaviors demonstrated adequate reliability and in most cases validity. The strongest and most consistent scales related to dietary behaviors were healthy eating change strategies and enjoyment. Consistent convergent validity was also found for the cons of change scales. These measures can be used in intervention studies to evaluate psychosocial mediators of dietary change in overweight and obese individuals.

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.

Action planning as predictor of health protective and health risk behavior: an investigation of fruit and snack consumption

BACKGROUND

Large discrepancies between people's intention to eat a healthy diet and actual dietary behavior indicate that motivation is not a sufficient instigator for healthy behavior. Research efforts to decrease this 'intention - behavior gap' have centered on aspects of self-regulation, most importantly self-regulatory planning. Most studies on the impact of self-regulatory planning in health and dietary behavior focus on the promotion of health protective behaviors. This study investigates and compares the predictive value of action planning in health protective behavior and the restriction of health risk behavior.

METHODS

Two longitudinal observational studies were performed simultaneously, one focusing on fruit consumption (N = 572) and one on high-caloric snack consumption (N = 585) in Dutch adults. Structural equation modeling was used to investigate and compare the predictive value of action planning in both behaviors, correcting for demographics and the influence of motivational factors and past behavior. The nature of the influence of action planning was investigated by testing mediating and moderating effects.

RESULTS

Action planning was a significant predictor of fruit consumption and restricted snack consumption beyond the influence of motivational factors and past behavior. The strength of the predictive value of action planning did not differ between the two behaviors. Evidence for mediation of the intention - behavior relationship was found for both behaviors. Positive moderating effects of action planning were demonstrated for fruit consumption, indicating that individuals who report high levels of action planning are significantly more likely to translate their intentions into actual behavior.

CONCLUSION

The results indicate that the planning of specific preparatory actions predicts the performance of healthy dietary behavior and support the application of self-regulatory planning in both health protective and health risk behaviors. Future interventions in dietary modification may turn these findings to advantage by incorporating one common planning protocol to increase the likelihood that good intentions are translated into healthy dietary behavior.

Nutritious food intake: a new competitive advantage for organizations?

Purpose

The purpose of this paper is to suggest that nutritious food intake is a somewhat overlooked yet essential aspect of corporate wellness that has the potential to help provide organizations with a sustainable competitive advantage.

Design/methodology/approach

The paper first discusses the resource‐based view, identifying ways in which nutritious food intake across an organization may serve to create rare and inimitable organizational resources leading to a competitive advantage. It then presents a basic overview of the fundamentals of nutritious food intake. It proceeds to review the transtheoretical stages of change model in the context of tailored nutrition interventions in organizations, providing a detailed overview of key individual behavior focused and environmental focused change strategies along with a discussion of types of technical delivery systems.

Findings

The paper suggests that an organization may be able to use a tailored stage‐based nutrition intervention as part of a comprehensive wellness program in order to help create a sustainable competitive advantage based on the nutritious food intake of its members.

Research limitations/implications

Future researchers should continue to examine the effectiveness of stage‐based computer tailored nutrition interventions and their delivery systems, particularly in the context of comprehensive corporate wellness plans and the extent to which this serves to create a competitive advantage through lower direct healthcare costs and higher worker productivity.

Practical implications

Organizational leaders should carefully consider the strategies and methodologies presented in this paper when designing and implementing nutrition interventions as part of a broad corporate wellness program.

Originality/value

This paper makes a valuable contribution to the organizational literature by recognizing the potential for the application of the transtheoretical stages of change model from the field of nutrition education within the context of the resource‐based view of organizations.

Planning health behaviour change: comparing the behavioural influence of two types of self-regulatory planning

OBJECTIVES

Recent efforts in health psychology to bridge the gap between individuals' intentions and behaviour have centered on the influence of planning strategies. This study investigated the impact of two commonly used types of self-regulatory planning in the prediction of health promoting behaviour.

DESIGN

This study employed a prospective longitudinal design. Three measurements were implemented in order to assess associations between various socio-cognitive determinants, planning, and health behaviour.

METHODS

Structural equation modelling (N = 572) was used to compare the value of preparatory planning, i.e. the planning of strategies and preparatory actions towards a goal behaviour, and implemental planning, i.e. the planning of when, where, and how to perform a goal behaviour, in the prediction of fruit consumption.

RESULTS

Both preparatory planning (ss = 0.21; p <.001) and implemental planning (ss = 0.13; p <.01) were significant predictors of fruit consumption, over and above the influence of motivational factors. Comparison of differences in explained variance (DeltaR(2)) indicated that the contribution of preparatory planning was larger than that of implemental planning (z = 2.19; p <.05). Implemental planning did not contribute to the prediction of fruit consumption over and above the influence of preparatory planning when tested simultaneously.

CONCLUSIONS

The results provide a first indication that the planning of strategic preparatory actions may be more influential in predicting health behaviour than implemental planning, focusing on when, where, and how to enact goal-directed behaviour. Implications of the results and suggestions for future research are outlined.

Assessment of stage of change, decisional balance, self-efficacy, and use of processes of change of low-income parents for increasing servings of fruits and vegetables to preschool-aged children

OBJECTIVE

Use the Transtheoretical Model of Behavior Change (TTM) to determine the proportionate stage of change of low-income parents and primary caregivers (PPC) for increasing accessibility, measured as servings served, of fruits and vegetables (FV) to their preschool-aged children and evaluate response differences for theoretical constructs.

DESIGN

Cross-sectional, quantitative survey design consisting of staging algorithm, construct scales, and food frequency questionnaire.

SETTING

Rural and urban communities in a southwestern state of the United States.

PARTICIPANTS

238 low-income PPC enrolled in federal nutrition education programs were recruited from group nutrition education sessions.

MAIN OUTCOME MEASURES

Stage of change using a staging algorithm, TTM constructs of processes of change, decisional balance, and self-efficacy measured by multiple-item scales using Likert response, and fruit and vegetable servings served using a food frequency questionnaire.

ANALYSIS

Descriptive analysis, Pearson's chi-square, analyses of variance with Tukey's Honestly Significant Difference post hoc test, and principal component function analysis.

RESULTS

Of the surveyed PPC, 43% were in precontemplation/contemplation stages, and 29% were in the preparation stage for increasing FV accessibility (measured by servings served) to their preschool-aged children. PPC in the action/maintenance stages evidenced greater use of behavioral processes and had higher self-efficacy scores compared to PPC in precontemplation/contemplation and preparation stages.

CONCLUSIONS AND IMPLICATIONS

Interventions aimed at increasing FV accessibility for preschool-aged children should be tailored to meet PPCs' stage of change. Interventions targeting PPC in precontemplation/contemplation stages should use methods to share ideas for planning meals and snacks to include FV. Interventions for PPC in the preparation stage should aim to build skills in quick preparation of economical FV, address parental role modeling of FV consumption, and encourage goal setting. Learning formats providing social support may prove effective in prevention of behavior relapse for PPC in action/maintenance stages.