Cardiovascular nurses, together with registered dietitians and other health professionals, have leadership roles to play in enabling implementation and uptake of the recently published 2015 Dietary Guidelines issued by the Department of Health and Human Services and US Department of Agriculture (USDA) (the Who and the What). The 2015 Dietary Guidelines focus attention on current evidence regarding dietary and activity recommendations and offer guidance regarding changing food environments including home, work, schools, and other community settings. Working together to make changes in all segments is recommended to produce significant positive change in health outcomes nationwide.
Individual Diet and Physical Activity Behavior Change (the What)
This section of the Dietary Guidelines Advisory Committee (DGAC) report provided recommendations on how to best encourage diet and physical activity behavior change to facilitate positive health outcomes. Behaviors mentioned for individual-level change included reducing screen time, eating less often at fast-food restaurants, increasing family shared meals, self-monitoring of diet and body weight, and food labeling to target healthy food choices.1
Healthy Diet Recommendations
The ”healthy diet pattern” in the 2015 Dietary Guidelines as compared with typical adult eating patterns was described as higher in vegetables, fruits, whole grains; low-fat or nonfat dairy, seafood, legumes, and nuts; moderate in alcohol; lower in red or processed meat; and lower in sugar-sweetened foods, drinks, and refined grains. This healthy diet pattern of eating was strongly associated with improved health and reduced chronic disease including cardiovascular disease (CVD) and type 2 diabetes.2 The USDA Food Patterns have now been updated to include 3 diet patterns that meet the 2015 Dietary Guideline recommendations. The patterns are the Healthy US-Style Patterns, Healthy Vegetarian Patterns, and Healthy Mediterranean-Style Patterns, and their components are listed in Table 1. These patterns of eating are recommended for all individuals older than 2 years, with variation in calorie levels depending on physical activity, age, and need.
At all calorie levels, in comparison with the Healthy US-Style Patterns, the Healthy Vegetarian Patterns include more legumes, processed soy products, nuts and seeds, and whole grains. They contain no meat, poultry, or seafood and are identical to the Healthy US-Style Patterns (the original USDA Food Patterns) in amounts of all other food groups. The Healthy Med-Style Patterns contain more fruit and seafood and less dairy than the Healthy US-Style Patterns. All of these patterns are a significant improvement over the “poor dietary patterns, overconsumption of calories and physical inactivity,” which typified the “fundamental realities described in the DGAC report that half of all American adults—117 million individuals—have one or more preventable chronic diseases and about two thirds of US adults—nearly 155 million individuals are overweight or obese.”4 Using the information summarized above, Healthy Vegetarian5 and Healthy Mediterranean-Style Patterns6 were developed at 12 different calorie levels. These patterns and the Healthy US-Style Patterns7 reflect 3 different approaches to consuming a healthy diet and are available for clinicians to use with patients and clients.
All 3 healthy food patterns are predominantly plant-based diets and also meet the sustainability goals first presented in the 2015 Draft Dietary Guidelines. The 2015 Draft DGAC report was the first time food sustainability and safety were addressed. Sustainability goals have since been removed from the final report. A sustainable diet was defined as higher in plant-based foods including vegetables, fruits, whole grains, legumes, nuts, and seeds and lower in calories and animal-based foods.8 This diet pattern was described as healthier and producing less negative environmental impact including land use, water use, energy use, and greenhouse gas emission than the current US diet.8 The Healthy Mediterranean Diet Pattern and the Healthy Vegetarian Pattern were also noted as providing similar benefits.8
In addition to providing recommended numbers of servings of individual food groups, patients need information in a format that is easy for them to remember and incorporate. One such format is to provide short messages such as the 10 tips for healthy eating and healthy living found in Table 2. These may be useful examples for facilitating discussion about healthy eating behaviors and positive eating behavior change with patients and clients. Messages should be clear, direct, positive, consistent, encouraging, and doable using simple language.
Motivating Patients to Change (the Why)
Behavior change is not easy for most patients especially when dealing with food choices because food represents family traditions, comfort, and memories of home and good times. Habits have been formed over long time frames with family and friends, and many people like what is most familiar to them, and that is especially true with foods. Health professionals play a major role in motivating positive health behaviors in patients. Although dietitians/nutritionists are extensively trained in nutrition science, food science, nutrition counseling, and nutrition education, all health professionals play an increasingly important role encouraging and supporting positive behavior change. Most people do not respond well to criticism or challenging their beliefs about food. Motivational interviewing, a counseling style that is based on a positive framework of assumptions about behavior change, has been shown to enable change in eating behaviors in diverse adolescent and adult populations.9
Food Environment and Settings (the Where)
The DGAC stated that the reviewed research provides clear evidence that “persistent, prevalent, preventable health problems notably overweight and obesity, CVD, type 2 diabetes and certain cancers have adversely affected the health of the U.S. public for decades and raise the urgency for immediate attention and bold action.” They recommend establishment of a “culture of health” where healthy lifestyle choices become easy, accessible, affordable, and normative. Because individual behavior change does not occur in a vacuum, the social, economic, and cultural environment may improve or deter access and the ability to choose and consume the recommended dietary patterns.1
In addition to changing individual diets of patients to improve health outcomes, several organizations, including the American Heart Association, are working to change workplace food environments to make healthier food choices more accessible to workers. The American Heart Association Tool Kit provides healthy workplace recommendations.10 Cardiovascular nurses and their dietitian colleagues are well positioned to lead efforts in making healthier food choices available in their work settings with the help of these readily available resources.
Opportunities to Improve Nutrition and Health Now (the When)
The new areas of emphasis in the 2015 Dietary Guidelines provide multiple opportunities for intervention for nurses and other healthcare professionals to be leaders in improving patient health outcomes, creating healthy food environments at home and at work, and generally supporting and creating a culture of health. Taken together, the guideline-based recommendations suggest new opportunities for leadership roles in prevention of CVD and chronic conditions including advocacy for policies that will improve the food (and physical activity) environments for diverse populations and encouraging uptake by healthcare providers, patients, and systems of healthcare. First and foremost, all health professionals need to encourage patients to change their diets to meet the 2015 Dietary Guidelines to improve their health. The DGAC Executive Summary states that “these strategies complement comprehensive lifestyle interventions and nutrition counseling by qualified nutrition professionals.”11
If patients are having difficulty or need nutrition assessment and evaluation of their environment to facilitate change, referral to a registered dietitian is warranted. Given the complexity of dietary behavior change, consumers will need recommendations for resources and intervention programs and services in public health and healthcare settings to facilitate adoption and maintenance of healthy dietary behaviors. We are responsible for mirroring those changes for our patients and showing them how to incorporate them into their homes, families, schools, worksites, and communities. This is a huge challenge and a great opportunity to make a difference in the health and well-being of our population.
The authors appreciate the careful review of the Progress in Prevention Column Editors.
9. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior
. New York, NY: Guilford Press; 1991.
10. American Heart Association. Healthy Workplace Food and Beverage Toolkit. 2015. www.Heart.org/foodwhereur
. Accessed September 15, 2015.