Facilitating a heart-healthy diet in patients involves several stages, and the process is based on theoretical models of change.1 A patient's decision to change dietary behavior may initially be precipitated by many different factors: a negative health event such as a disease diagnosis, heart attack or stroke, out-of-reference range laboratory values, family history risk assessment, family illness, or even family death. The transtheoretical model proposes that health behavior change is characterized by moving through 6 stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Assessment of readiness to change is the first step in helping patients change behavior.1 Unfortunately, many at-risk populations have been found to be in the early stages of behavior change rather than the action stage indicating readiness to make health behavior changes.2 Prochaska and Velicer2 reported that the basic rule of thumb for at-risk populations is that 40% are in the precontemplation phase, 40% are in the contemplation phase, and 20% are in the preparation phase. The health professional's role in increasing patients' readiness for change is to help them transition to the preparation, action, and maintenance stages of behavior change. When a patient's readiness to change has been assessed and established, 2 essential elements to facilitate behavior change are needed related to reduction of heart disease risk. One is understanding the benefits of a heart healthy diet in reducing heart disease risk and knowledge of specific dietary changes to reduce the individual's risk of heart disease. The second is self efficacy that comes from skill development to reduce barriers and achieve the desired changes.
Empirical evidence regarding the benefit of a healthy diet in reducing cardiovascular disease risk should be used to increase patient knowledge. This information includes studies examining the long-term effect of following a healthy diet related to risks of heart disease, diabetes, and mortality. Brunner et al3 examined dietary patterns and 15-year risk of coronary events, diabetes, and mortality. In the healthy-diet group who basically followed the current American Heart Association (AHA) nutrition guidelines, the rates of incidence-verified nonfatal myocardial infraction and coronary death were 37% lower and rates of diabetes were 34% lower than those following the unhealthy diet. Health promotion advice was most effective in high-risk individuals ready for change combined with a personalized approach.3
The dissemination of relevant information to increase knowledge for the purpose of changing dietary behavior is paramount in the process. Nutrition counseling has traditionally focused more on nutrition education than counseling under the assumption that the provision of nutrition information to patients results in improvement in eating behavior. However, increased knowledge alone does not always result in behavior change. Furthermore, patients need to understand the relationships between diet and disease and to know which foods in what combination and quantity are best for their particular disease prevention. Successful behavior change is predicated on the existence of a patient who is ready to change and has the confidence that dietary changes will be beneficial along with a belief that new skills learned and implemented will result in the desired health benefit. Current practice dictates that the assessment of these factors is paramount in facilitating positive dietary behavior change compared with knowledge dissemination alone.1
Despite evidence delineating the effective components needed for patients to achieve successful dietary behavior change, many individuals do not receive this help. Most individuals receive their nutrition information from sources other than health professionals.4 The International Food Information Council reported the top sources and most believable sources for patient nutrition information in its survey of 1000 adults conducted in 2007.4 Seventy-one percent of consumers named the news media as their top source of health and nutrition information, and 52% named the Internet. Thirty-six percent named medical sources including physicians as their top source and most believable source of nutrition and health information. However, the decision to try a food or food component was greatly influenced by health professionals, with 84% listing them as most influential. Dietitians (76%) and health associations (74%) were also very influential. Interestingly, diet and health books for consumers were not considered top sources by many (3%) or most believable (0%).
The AHA represents one health association that provides diet and lifestyle recommendations in a variety of formats (Table 1). These recommendations include 3 simple steps for a heart-healthy diet, which are (1) use up to at least as many calories as you take in, (2) eat a variety of nutritious foods from all the food groups, and (3) eat less of the nutrient-poor foods.5 Unfortunately, although these steps may be simple, they may also be difficult to execute, given the obesity-promoting environment. Therefore, barriers related to the environment should be identified and resolutions implemented as necessary.
Common barriers to implementing the dietary changes recommended by the AHA nutrition guidelines were recently identified.6 Barriers identified include the following:
* chaotic lifestyles characterized by families rarely eating together
* children with multiple caregivers throughout the day
* no one person oversees quantity and quality of food consumed
* frequent eating out particularly at fast-food restaurants
* complex work schedules
* single parenting
* underdeveloped parenting skills
* inadequate structuring of meal times, sleep schedules, or physical activity routines
* lack of family rules that enforce expectations around eating, sleeping, and playing
* limited food preparation skills
* low knowledge of daily caloric and nutritional needs
* nutrition beliefs/attitudes hostile to a healthy-diet pattern
* cost, mood, and convenience rather than health-driven food choices
* susceptible to incorrect food messaging
* the belief that overweight is normal
Americans do not eat enough fruits and vegetables despite knowledge of the benefit of including them in the diet. Fruits and vegetables are high in vitamins, minerals, phytonutrients, and fiber and low in calories and should be the cornerstone of a healthy diet as they are associated with a lower risk of cardiovascular disease, particularly stroke.7,8 However, according to the 2008 International Food Information Council consumer survey, 13% of consumers reported eating 5 or more servings of fruits and vegetables each day, whereas 55% reported eating 1 to 2 servings per day.9 Barriers to fruit and vegetable intake include access, availability, familiarity, cost, and preparation time as well as the family characteristics previously listed.The latest American Heart Association recommendations for diet state "In the context of a diet that is appropriate in energy balance, pursuing an overall dietary pattern that is consistent with a DASH (Dietary Approaches to Stop Hypertension)-type eating plan, including but not limited to: Fruits and vegetables: > or equal to 4.5 cups per day."10
Recommendations for how to increase fruit and vegetable intake are composed of 2 parts: assessment and counseling. To begin, assessment of family dynamics and existing barriers is performed. Subsequently, counseling directed toward family barriers should be done first rather than addressing goals related to specific intake. Once barriers have been addressed, simple steps to increase daily intake may include incorporation of salads and/or vegetable soups at lunch and dinner, fruit for snacks, involvement in shopping, growing fruits and vegetables such as community gardens, and stealth nutrition such as adding carrots and other vegetables to pasta sauces or other foods such as casseroles or baked goods.
An additional barrier for consumers may be changes in food packaging, which increase difficulty in understanding and/or interpreting nutrition information on foods and food labels. Some of the more confusing products currently include whole-grain products, healthy and unhealthy fats, and beverages. Problems associated with understanding food product package information combined with an abundance of new products in grocery stores and other food outlets make it more difficult and time consuming for consumers to make knowledgeable and appropriate food choices.
Starting May 1, 2009, a food industry organization called the Whole Grains Council, which developed a whole-grain stamp for food products, containing whole grains. The Dietary Guidelines for Americans 2005 recommend 48 g/d or 3 servings and at least half of grains eaten a day should be whole grains.11 The AHA guidelines state "choose whole-grain, high-fiber foods."5
For consumers, the stamp may help identify foods that contain whole grains, but there may be a learning curve involved in the accurate interpretation of this stamp. One example is that simply adding 8 g of whole grain to a food that is not a nutritious choice will not make it a nutritious choice. Recommending that consumers look for a whole grain as the first ingredient on the food product label may be more helpful advice when comparing products. Table 2 includes a list of common whole-grain foods eaten in the United States in order of most consumed to least consumed. The latest American Heart Association dietary goals state "In the context of a diet that is appropriate in energy balance, pursuing an overall dietary pattern that is consistent with a DASH (Dietary Approaches to Stop Hypertension)-type eating plan, including but not limited to: Fiber-rich whole grains (> or equal to 1.1 gram of fiber per 10 g of carbohydrate): > or equal to three 1-oz-equivalent servings per day."10
When looking for healthy fats, the AHA guidelines offer "limit your intake of saturated and trans-fat and cholesterol."5 To limit saturated fat, the focus should be on eating lean meats and vegetable alternatives; choosing skim, 1% fat, and low-fat dairy products; and minimizing intake of partially hydrogenated fats. Partially hydrogenated fats are primarily found in commercially fried and baked products such as preprepared foods and packaged cookies, crackers, desserts, and snack items. Choosing more fresh items from the outer circle of the grocery store rather than the inner aisles is an easy tip. The mandatory trans-fat labeling effective in 2006 allows consumers to more easily identify sources of trans-fat and trans-fat-free foods. The latest American Heart Association dietary goals state "In the context of a diet that is appropriate in energy balance, pursuing an overall dietary pattern that is consistent with a DASH (Dietary Approaches to Stop Hypertension)-type eating plan, including but not limited to: Fish: > or equal to 3.5-oz servings per week (preferably oily fish).10
Beverages are also specifically addressed in the AHA diet and lifestyle recommendations with this advice: "Minimize your intake of beverages and foods with added sugars."5 The most recent American Heart Association dietary goals state "In the context of a diet that is appropriate in energy balance, pursuing an overall dietary pattern that is consistent with a DASH (Dietary Approaches to Stop Hypertension)-type eating plan, including but not limited to: Sugar-sweetened beverages: < than or equal to 450 kcal (36 oz) per week." Health professionals often recommend water as the beverage of choice, and consumers are now offered enhanced water or water beverages containing other ingredients such as vitamins, minerals, and herbs as well as sugars. Adding caloric sweeteners to water beverages contributes calories without additional nutrient value. Sweetened beverages offer limited satiety value and thus may contribute to weight gain.12 Whereas vitamins are essential nutrients, consumers may think purchasing vitamin-enhanced water is beneficial, while the cost of vitamin-enhanced water may be as high as 15 times what a multivitamin supplement would provide. Educating consumers about what dietary changes will reduce their risk of heart disease and other chromic illness should include a prioritization of which changes are most critical and beneficial to them considering their risk and also reminding them "don't sweat the small stuff."
How are we doing in changing behaviors related to a heart-healthy lifestyle and diet? Ma et al13 recently reported that 1 year after diagnosis of heart disease and performance of angioplasty, 12.4% of 555 patients met recommended consumption of vegetables, 7.8% met recommended consumption of fruit, 8% met recommended consumption of fiber, and 5.2% met recommended consumption of trans-fat. Lower dietary quality was associated with smoking, obesity, and lower educational level.14 Is this a knowledge deficit, a lack of readiness, a motivational issue, a lack of confidence that change will be beneficial, or inability to make the necessary changes in terms of resources and skills? Practitioners must be ready to assess all of these factors to best help clients improve lifestyle risk factors.1,2
Studies have determined self-efficacy as an important factor related to the successful adoption of health-promoting behaviors including higher levels of healthy eating14,15 and moderate levels of physical exercise.16 Overweight or obese individuals have reportedly low self-efficacy regarding the selection of healthy foods and strategies to enable and reinforce physical activity.14,16-18 Participants in a qualitative study of Northeast Florida residents indicated that self-efficacy was an important factor for successful weight management and risk factor reduction.19 Strategies to enhance self-efficacy by improving healthy-eating skills including fast-food and grocery store tours, eating-out guides, and shopping lists for specific disease risk reduction were implemented and were associated with increased eating self-efficacy in a community-based program in the same county.20 Increasing knowledge about specific personalized dietary changes needed and skills practice making those changes can result in increased healthy-eating self-efficacy and behavior change.14 However, patients often view dietary change as black or white. They are either on the diet or off the diet. Dietary change is not all or nothing. Introducing patients to the 90-10 rule applied to food choices may help them see the big picture. It is what you do 90% of the time that matters, not 10% of the time. Helping patients learn how to allow some flexibility in their eating choices while still achieving desired risk reduction is also important. One example might be establishing a pattern of healthy eating most of the week but having 1 meal a week as a time to include other foods or beverages. The knowledge of what foods are an acceptable substitute and what the dietary priorities are in terms of restrictions and additions can help patients decide how to include restricted foods occasionally with the least potential harm. If the new eating pattern is viewed as totally restrictive, patients may experience food cravings and be less likely to maintain it. The 90-10 rule can make changing any lifestyle behavior more palatable and doable, thus enhancing the patient's self-efficacy around those behaviors and the likelihood of success. Eating well most of the time is the ultimate goal. Whether that means 90% or 85% or 80% of the time may be different for each individual, depending on personal risk. More research is needed in terms of how much variation there can be in prescribed dietary adherence while still achieving the heart-healthy risk reduction that is needed and desired.
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6. Giddings S, Lichtenstein AH, Faith MS, et al. Implementing American Heart Association Pediatric and Adult Nutrition Guidelines: A scientific statement from the American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular Disease in the Young, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Circulation
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