The organization of dietary data based on adherence to change in nutrition lifestyle can be of benefit in terms of designing nutrition intervention programs.
Because of the streamlining of the Prochaska/DiClemente model to include three stages of change — sure, unsure, and not ready to change
— an automatic categorization of nutrition lifestyle change is available.
This is one way of tailoring a nutrition intervention to a particular stage of readiness. Chapters 5, 6, and 7 provide specific ways of counseling for each stage of change in each lifecycle stage.
This method was not used in the Women’s Health Initiative to classify adherence because other factors were also important as we worked to improve adherence. Table 12.1 describes the four levels of adherence to Women’s Health Initiative goals, with 1 being best and 4 being worst.
This system of numbering did not mean that for those doing well at level 1 no attention was given because that would lead to an increase in the level of categorization with reduced adherence to dietary lifestyle change.
Likewise, too much emphasis on a person in level 4 might lead to no change and would be wasted effort. Levels 2 and 3 are the levels with most promise for improvement and movement to level 1.
Several factors were important to ultimate nutrition lifestyle change:
attendance at sessions, self-monitoring, and compliance with the diet regimen including fat gram, fruit and vegetable servings, and grain serv- ings. By classifying adherence data we have a way of identifying problems with all of the patients we are counseling. For groups, this will provide
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Table 12.1Four Levels of Dietary Adherence in Women’s Health Initiative Participants Triage staff efforts beginning with participants in Level 1 and ending with participants in Level 4. Focus time and effort on improving adherence to the fat gram goal and self-monitoring through Additional Assistance activities with participants in Levels 2 and 3. Adherence LevelStaff Time and EffortParticipant EffortAdherence Activities 1Completes sessions and meets fat gram goalReaffirm and encourage meeting fat gram goal Reward self-monitoring and session attendance by giving positive feedback. 2Completes sessions and self-monitors but does not meet fat gram goal
Conduct Additional Assistance using participant-centered counseling. Assess: Have participant identify problem(s) interfering with reaching fat gram goal. Discuss participant’s readiness and confidence to change. Negotiate and Motivate: If ready to change, then negotiate a plan for change — have the participant identify the steps. If not ready to change, help the participant move closer to change — help the participant develop dissonance and explore ambivalence about change. Arrange: Work with the participant to arrange future contact.
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Organizing Data on Dietary Change 125
3Completes sessions, but does not self-monitorConduct additional assistance using participant-centered counseling. Assess: Have participant identify problem(s) interfering with self monitoring. Discuss participant’s readiness and confidence to change. Negotiate and Motivate: If ready to change, then negotiate a plan for change — have the participant identify the steps. If not ready to change, help the participant move closer to change — help the participant develop dissonance and explore ambivalence about change. Arrange: Work with the participant to arrange contact. 4Completes 1 sessionNegotiate interrupted DM intervention participation. = no additional effort; = extensive additional effort
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a system of identifying similar problems. For individuals, it targets groups of problems that may affect subsets of those we are counseling.
Patient-centered counseling where the patient is involved in discussions around what might work to remediate nutrition lifestyle change problems is a key to achieving change. For example, in group counseling, those patients who are not attending sessions routinely might all be given an assessment of why attendance has tapered off. Additionally, patients might be asked what strategies they wish to use to increase attendance.
For those who need assistance with self-monitoring, new streamlined strategies might be used. Some of the most creative and useful self- monitoring tools have been designed by participants. One cr eative approach was designed around beads on a bracelet, where each time a gram of fat was eaten beads were moved to a different location on the bracelet. By the end of the day all of the beads should have been relocated, thus showing goal attainment. This creative approach to self-monitoring was something only a person who had dealt with r eal-life situations involving nutrition lifestyle change could have devised. The counselor who tries to have all of the answers often misses the creative talents of the individual she or he is trying to help.
12.2 PRESENTING DIETARY ADHERENCE DATA