Serum Vitamin C (mg/dl) by Salad Intake

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Serum Vitamin C (mg/dl) by Salad Intake
State of the Evidence Regarding Behavior Change
Theories and Strategies in Nutrition Counseling
to Facilitate Health and Food Behavior Change
Joanne M. Spahn, MS, RD, FADA Center for
Nutrition Policy and Promotion Rebecca S. Reeves,
DrPh., R.D., FADA Baylor College of
Medicine Kathryn Keim, PhD, RD, LDN Rush
University Ida Laquatra, PhD, RD H.J. Heinz
Company Molly Kellogg, RD, LCSW Bonnie Jortberg,
MS, RD, CDE University of Colorado Denver School
of Medicine Nicole Clark, MS, RD, CDE, LDN
University of Indiana of Pennsylvania
JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
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Serum Vitamin C (mg/dl) by Salad Intake
Why Theory-Based Interventions and Strategies

• Evidence-base for nutrition counseling
• Critical to the nutrition care process (NCP)
• Nutrition assessment
• Selection of intervention strategies
• Monitoring and evaluation indicator use
• Enhances provider impact
• Builds knowledge-base of the profession

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
3
Serum Vitamin C (mg/dl) by Salad Intake
Question Format

• What is the evidence that nutrition counseling
• based on __________results in health/food
• behavior change in adults counseled in an out
• patient or clinic setting?

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
4
Serum Vitamin C (mg/dl) by Salad Intake
Cognitive Behavioral Therapy (CBT)

• Plethora of evidence (45 articles)
• Significant effect with all groups
• Strong evidence for interventions
• Long-term (gt18 months) targeting Cardiovascular
  Disease (CVD)
• Long-term (gt12 months) for diabetes prevention
• Intermediate length for diabetes management

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
5
Serum Vitamin C (mg/dl) by Salad Intake
Cognitive Behavioral Therapy

• Fair evidence for intervention
• Long-term (gt 12 months) for weight management
• Short-term (lt 6 months) for diabetes management
• Additional research needed to address
• Maintenance of benefits achieved with CBT

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
6
Serum Vitamin C (mg/dl) by Salad Intake
Cognitive Behavioral Therapy

• Beneficial in facilitating modification of
  targeted dietary habits
• Decreased calories from fat
• Decreased sodium
• Increased intake of fruits vegetables
• Weight, CVD diabetes risk factors
• Grade 1

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
7
Serum Vitamin C (mg/dl) by Salad Intake
Group versus Individual Counseling

• Research available for diabetes/weight only
• Three Randomized Controlled Trials (RCT)
  evaluated diabetes or weight management for
  middle aged subjects
• Positive quality studies
• 3-6 month intervention duration
• Groups significantly more effective Attrition
  rates high in two studies
• Grade II

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
8
Serum Vitamin C (mg/dl) by Salad Intake
Transtheoretical Model

• One RCT supported
• Impact of Stage of Change appropriate counseling
• Stage matched materials targeting diabetes
• Personalized assessment reports, monthly phone
  calls and newsletter every other month
• Grade III
• Much research to validate instruments in dietary
  context
• Little intervention research in adults

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
9
Serum Vitamin C (mg/dl) by Salad Intake
Social Cognitive Theory

• One RCT - positive effect on reducing saturated
  fat cholesterol intake
• 6 telephone sessions
• Targeted to self-efficacy
• Verbal persuasion
• Goal setting
• Self-monitoring
• Self-reinforcement
• One RCT in diabetes no added benefit to an
  education intervention
• Grade III

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
10
Serum Vitamin C (mg/dl) by Salad Intake
Question Format

• What is the evidence that the behavioral strategy
• of _____, used as a component of a behavioral
• program, will result in health or food behavior
• change in adults counseled in an outpatient or
• clinic setting?

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
11
Serum Vitamin C (mg/dl) by Salad Intake
Grade I

• Self-monitoring
• Three RCTs, three observational studies
• Reward strategies
• Two RCTs, one meta-analysis
• NOT effective
• Motivational Interviewing
• Meal replacements or structured meals
• Four RCTs
• Compared to self-selected diets

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
12
Serum Vitamin C (mg/dl) by Salad Intake
Motivational Interviewing (MI)

• Used alone, no more effective than usual
  treatment
• Four RCTs added MI session(s) to CBT
• Enhanced adherence to program
• Improved outcomes
• MI as phase one
• CBT as phase two

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
13
Serum Vitamin C (mg/dl) by Salad Intake
Grade II

• Problem-solving
• Two small RCTs
• Social support
• Mixed results. More research needed
• Client self-selected goal setting
• Realistic, measurable
• Included goal attainment training
• Two RCTs

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).
14
Serum Vitamin C (mg/dl) by Salad Intake
Grades III IV

• Grade III
• Cognitive restructuring
• One RCT
• No effect
• More research needed
• Grade V
• Stress management
• Stimulus control

JOURNAL OFTHE AMERICAN DIETETICASSOCIATION
Spahn, J., et al. J Am Diet Assoc. 2010 Volume
110 (June).