7
Dietary Behaviors: Promoting
Healthy Eating
CYNTHIA A. THOMSON
GARY D. FOSTER
LEARNING OBJECTIVES
•	 Barriers to dietary behavior change are present at the individual, social, and environmental
levels. For each level, list at least two barriers commonly identified.
•	 Describe why the distribution of educational materials alone is unlikely to promote change
in eating behaviors.
•	 Understand the relevance of behavioral theories and constructs in the promotion of eating
behaviors.
•	 List three behavioral approaches used in patient-centered counseling to promote changes
in eating behaviors.
Current dietary intake patterns in Americans have been well described. The recurring
NHANES data (National Center for Health Statistics, 2012; www.cdc.gov/nchs
/nhanes.htm) based on self-reported dietary intake suggest that Americans are, on
average, consuming diets incongruent with the Dietary Guidelines for Americans
(2012) (health.gov/dietaryguidelines). Specifically, intake of dietary fat, saturated fat,
sodium, and sugar-sweetened beverages and not including fiber, fruits and vegetables,
and omega-3 fatty acids (USDA, What we eat in America; www.ars.usda.gov/Services
/docs.htm) are well above what is estimated to be optimal for health. Further, dietary
components whose greater intake is thought to be important for health are consumed
well below estimated requirements. The resultant dietary patterns suggest poor eating
behaviors predominant in the American diet. Alarmingly, these patterns have persisted
for several decades and are a major contributing factor in the current epidemic of overweight/obesity
and obesity-related chronic diseases such as diabetes, cardiovascular
disease, as well as several cancers (Centers for Disease Control and Prevention, 2012;
www.cdc.gov/chronicdisease/index.htm). This disconnect between what we select to
eat and the strong and well-substantiated risk for disease when less healthy food selections
are made has led to a resurgence in interest to more thoroughly explore eating
behavior. Furthermore, behavioral counseling remains a central therapy to reduce the
burden of chronic disease in U.S. adults (Lin et al., 2010). Food choices are complex and
Thomson, C. A., & Foster, G. D. (2014). Dietary behaviors: Promoting healthy eating. In K. A. Riekert, J. K. Ockene, & L. Pbert (Eds.),
The handbook of health behavior change (4th ed., pp. 139–154). New York, NY: Springer.
140	III. Lifestyle Change/Disease Prevention Interventions
represent a variety of motivational factors ranging from taste/satisfaction, to psychosocial
distress, to health, thus making absolute and sustained change challenging.
Importantly, humans must eat to survive and be healthy; thus avoidance is not a
sustainable approach to positive eating behavior change. Eating behaviors require multiple
choices repeated on a daily if not hourly basis. Each stimulus to eat from hunger, to
visual cues, to smells or taste, most commonly acts to promote greater intake of food. The
increasing abundance and availability of food also have promoted greater intake over
time. But beyond the abundance and repeated exposures, research has suggested that
the decision to select healthier less energy dense foods is both biological and behavioral.
This chapter serves to inform approaches to dietary behavior change by briefly
reviewing the biology of eating; reviewing relevant behavioral theories, constructs, and
strategies that have been effectively applied for changing eating behaviors; as well as
exploring modification of the environment to promote healthy eating behaviors. The
content is largely focused on individual behavior change; however, increasingly there
is awareness that policy and population-level change also will be necessary in order
to achieve the magnitude of sustained change in eating behavior necessary to make
­wellness a reality at the population level.
THE BIOLOGY OF EATING BEHAVIOR
The drive to consume energy is largely driven by paracrine, endocrine, metabolic, and
hormonal signaling pathways (Sam, Troke, Tan, & Bewick, 2012; Wren & Bloom, 2007).
To a lesser extent, diurnal variations in hormones such as estrogen also can influence
energy consumption as can thermal influences such as fever and the rise in core temperature
with intense physical activity. Figure 7.1 illustrates several of the key regulatory
factors within the brain, orosensory system, and gastrointestinal tract that regulate
intake. While the human body has sophisticated regulatory feedbacks to optimize
energy control, it is clear that behavioral factors can have a profound impact on these
Higher brain centers
(Hedonic mediators)
Food intake Food intake
Gut hormones
Intestinal
L-cell
Vagus nerve
Nutrient sensing G-protein
receptor, e.g., GPR 119
Hypothalamus
Brainstem
Food
PYY
GLP-1
CCK
PVN
ARC
NPY
AgRP
POMC
FIGURE 7.1  Biology of eating behavior. (Adapted from Sam, et al. 2012)
	 7.  Dietary Behaviors: Promoting Healthy Eating	141
systems, particularly within the human brain and gastrointestinal tract. Further, the heterogeneity
of the biological influences on eating behavior at the individual level suggests
that behavioral therapy to promote changes in eating behavior will have highly
variable responses as is consistently demonstrated in practice and clinical trial research.
THE BEHAVIOR OF EATING
Beyond biology, there is a significant and not fully understood role for behavior in food
choices. Behavioral influences on intake include conditioned responses such as food
preferences, aversions, and satiations as well as cognitive behavioral factors such as
social, cultural, and esthetics. In addition, ecological influences such as relative densities
and nutrient drivers also must be considered when examining the role of behavior
on dietary choices. To illustrate in a more applied way, behavioral influences include a
variety of factors such as stimulus response (e.g., chocolate as a “comfort food”), knowledge
(e.g., consume calcium-rich dairy for bone health), social influences (e.g., mom said
eat your vegetables), behavioral norms (e.g., daily lattes), role modeling (e.g., grandpa
always avoided salt), aversions/attitudes (e.g., olives make me ill), and even reinforcement
(e.g., coffee, beer taste wonderful).
Approaches to help individuals modify their eating behaviors, generally in an effort
to support attainment of the Dietary Guidelines for Americans or some adaptation
thereof, require behavioral treatment or other interventions. The distinguishing characteristics
of behavioral treatment have been described by Foster and colleagues (Foster,
Makris, & Bailer, 2005). Specifically effective behavioral treatment as it relates to eating
and other behaviors must be goal directed, process oriented, and advocate for small
rather than large change. Frequently the approach will integrate multiple components
from ­self-monitoring to stimulus control, to cognitive restructuring.
INDIVIDUAL DIETARY BEHAVIOR CHANGE
Individual behaviors surrounding food choices may reflect personal health behavior,
health-related behavior change, or health (dietary) protective behavior. Personal health
behavior reflects food choices made that result in a direct effect on the individual’s
health. These behaviors may or may not be driven by a desire to improve one’s health
as food choices are more commonly the result of taste, habits, availability, beliefs, and
attitudes that may indirectly alter health status despite the original or primary motivational
factor driving the eating behavior. Health-related behavior change differs from
personal health behavior as it captures behaviors of others that indirectly improve the
target individual’s health status. This would include behaviors of friends, family members,
or perhaps even administrators and policymakers that affect the eating behavior
of others. Health protective eating behaviors are behaviors that are undertaken with
the primary, if not the sole intent, of improving a specific health indicator (e.g., serum
cholesterol, blood pressure, etc.) whether it is risk for disease or control/treatment of
disease.
At the individual level, changing dietary behaviors have historically relied on
trained professionals (registered dietitians, medical doctors, registered nurses, etc.)
who provide some specific facts or knowledge for the individual using an advice-giving
mode in an attempt to elicit the desired change. While this approach in a small percentage
of individuals may result in modest improvements in food choices to support
health, there is a significant body of literature demonstrating that these approaches to
behavior change fail in terms of magnitude of change needed as well as duration of
142	III. Lifestyle Change/Disease Prevention Interventions
change realized. Individuals trained in Behavioral Medicine are not surprised by these
results in that these approaches often fail to engage the patient/client in the decisionmaking
process or to ensure that the patient/client has made a conscientious effort to
determine the value of specific dietary behavior changes in the context of their own
risk–benefit evaluation. Yet these approaches are broadly applied even in current health
care practice. A more productive client-centered approach that engages the client in
developing plans and motivation for change has been demonstrated to be effective
(Ockene et al., 1999). Beyond imparting knowledge and engaging the client, efforts also
have been undertaken to identify barriers to making healthy food choices. Table 7.1 lists
several of the more commonly reported barriers for which plans to reduce or remove
the barrier may support positive changes in eating behavior. Again, reducing or removing
barriers while shifting the risk–benefit ratio may or may not promote the magnitude
and sustained change in eating behavior being sought.
Habituation as a Determinant of Food Intake
Epstein and colleagues have recently suggested that habituation of food intake is an
important determinant of food selection and thus may be an important determinant of
resistance to change in food choices (Epstein, Temple, Roemmich, & Bouton, 2009). Food
intake, in this context, is the result of repeated exposure to orosensory cues that drive the
decision to eat. These same cues also may drive decisions related to stoppage of eating
and thus also contribute to an individual’s propensity toward obesity. To dishabituate
a behavior is challenging in that it requires both an awareness of the habit and cues
stimulating a specific eating decision and also the capacity to alter or over-ride these
TABLE 7.1  Barriers to Change in Eating Behaviors to Achieve Recommended
Diet Intake Patterns for Optimal Health
Individual Lack of knowledge
Financial/food insecurity
Lack of or limited motivation
Low perceived risk; insufficient benefit
Hunger
Taste
Lack of awareness; mindfulness
Habituation of food intake
Social Cultural norms
Holiday or religious practices
Family composition/social isolation
Meals consumed at home or away from home
Shared meal environment
Lack of social support for healthy behaviors
Environmental Food accessibility; lack of supermarkets
External stimulus; media
Frequency of food exposures
Quality of food exposures
	 7.  Dietary Behaviors: Promoting Healthy Eating	143
habit-associated cues in an effort to make a different decision around the food behavior.
To dishabituate, stimuli will need to be removed or altered. For example, food consumption
is positively associated with television viewing time (Sisson, Shay, Broyles, & Leyva,
2012), particularly when combined with the availability of unhealthy snacks in the home
(Pearson et al., 2012). Thus, setting a short-term goal to avoid visual stimuli from electronic
sources overall and perhaps particularly during meal times will likely promote a
reduction in intake. Other stimuli that should be considered include, for example, who
the meal is shared with, time of day, smell of the food, visual access to the food, and
related factors that may promote what has been labeled as “mindless eating” (Ogden
et al., 2013; Wansink, 2010).
PROMOTION OF HEALTHY EATING BEHAVIORS
EDUCATION
There are several approaches to behavioral change. Commonly, health care providers
employ one-way delivery of information, or education, in an attempt to help patients/
clients change eating behavior. For example, clinicians may provide dietary handouts
explaining how to reduce dietary fat, salt/sodium, or even portion sizes. Lack of information
is a barrier to effective change in dietary behaviors and evidence exists to suggest
that filling knowledge gaps can enhance diet change toward healthier food choices
as was the case for the nutrient-rich foods consumer education program for adult primary
food shoppers (Glanz et al., 2012). Many times these materials are printed in mass
without formative work to determine patient understanding, interpretation, and/or
ability to employ the information to change their dietary behavior. In some cases, the
materials are not adapted for cultural norms or expectations or may reflect a relatively
verbatim translation without modification for cultural context. Seldom is health literacy
evaluated during the development of the educational handouts resulting in educational
handouts that frequently include medical terminology, mathematical computations,
and reading levels that are beyond the literacy level of the target population. Further,
this unidirectional approach is unlikely to be effective given the complexity of eating
behavior and the multiplicity of factors that contribute to the individual’s risk-to-benefit
assessment that can lead to significant changes in food choices. In particular, dissemination
of information without application of behavioral theory is likely to ignore important
psychological, social (inter- and intrapersonal), environmental, cultural, and even
economic constraints. Importantly, even if the information provided through education
fills a gap in the patient/client’s knowledge, there is limited evidence that education
alone impacts behavior change in relation to achieving complex eating goals.
BEHAVIORAL THEORIES AND CONSTRUCTS
A number of behavior change theories have been applied to dietary behavior. ­Commonly
applied theories and constructs are described below (see Chapter 1 for a more in-depth
discussion of these theories). But dietary behavior is not only complex in terms of the
individual decision to eat or not eat a given food item; this decision-making process is
repeated multiple times throughout a day and continuously in an individual’s lifetime.
Theories developed to help individuals change eating behavior must consider multiple
factors at the individual, social unit, and population level that influence and inform
each decision to consume or not consume food. Figure 7.2 illustrates the complexity of
these interacting influences on eating behavior.
144	III. Lifestyle Change/Disease Prevention Interventions
Health Belief Model
The Health Belief Model can be effectively used to promote eating behavior particularly
among individuals who have true elevated risk for disease. Cues that promote eating
behavior change under this model include when an individual experiences a family
member or close friend diagnosed with a disease, sees a media campaign or report suggesting
disease risk, or is notified by a health care provider that risk is elevated. This
theory suggests that first an individual must feel personally threatened or susceptible
to a disease and second the individual must believe that the benefits of taking action
outweigh the risks. When promoting eating behavior change using the Health Belief
Model, interventionist and health care providers should consider both how change in
behavior can be incentivized to increase the benefit beyond reducing health risk alone
and/or target risks of dietary behavior change along with self-empowerment strategies
to build the patient/client’s capacity to manage the necessary change in diet. The challenge
with this theory of behavior change is that health beliefs are only one influence
on eating behaviors so that perceived risk must not only be heightened above other
influences it also must remain heightened over other influences (cultural, social, and
personal) over time in order to sustain the behavior change. Individuals who are commonly
considered appropriate for whom to employ health belief models of dietary
behavior change include cancer survivors and their family members, and individuals
with newly diagnosed metabolic syndrome, pre-hypertension, or perhaps premalignant
lesions (adenomas, abnormal mammography, and actinic keratosis).
Social Cognitive Theory
Social Cognitive Theory builds on the interaction between personal factors and the
environment suggesting that both influence each other leading to reciprocal causation
Life-course experiences and influences
Personal food system
Values/ideals Personal factors Resources Social factors Context
Value negotiations
Relationships
Health
Cost
Convenience
Taste
Strategies
Food choices
And the
interactions
FIGURE 7.2  The Food Choice Model. (Adapted from Furst, Connors, Bisogni,
Sobal, & Falk, 1996; Sobal & Bisogni, 2009)
	 7.  Dietary Behaviors: Promoting Healthy Eating	145
in relation to eating behavior. In this model, eating behavior is thought to be a function
of modeling or observed learning which is then reinforced to promote self-efficacy.
Individuals learn how to make a specific dietary behavior change through observation
and experiential learning (e.g., cooking demonstration, grocery store food purchasing
trips, and role playing). As the individual practices the modeled behavior and increases
awareness of the expected outcomes, self-efficacy is increased and eating behavior
changes are effectively made. In this approach to dietary behavior change, it is important
to consider significant others who play an active role in modeling the behavior
of choice as well as environmental factors that may need to be considered to promote
self-efficacy.
Social Determination Theory
Social Determination Theory (SDT) is an integration of other theories into a larger context
and is based on the premise that reinforcement and environmental contingencies
are highly effective in influencing behavior, but must remain in effect for behavior to
be sustained. Both the person/personality in relation to motivations and self-regulation
as well as the situation or social context motivate behavior. This theory considers four
regulations for the continuum of extrinsic motivation as shown in Figure 7.3. Counseling
that applies SDT will likely initiate with autonomy supportive behaviors that
address the patient’s current perspectives and emotions, followed by problem solving,
identification of patient aspirations in relation to goal setting, and in follow-up, the integration
of competence support (Deci & Ryan, 2012). For example, a patient may be entering
the diet counseling session for hypertension control but be overwhelmed with a
new job. This issue should be acknowledged and emotions addressed, followed by a
transition to the focus of the counseling, determining the patient’s aspirations and thus
longer term goals for dietary health, and then problem solving perhaps around shortterm
goals for healthy choices in the new work environment, behavioral efforts that
can then be re-evaluated to promote self-efficacy over time within future counseling
sessions. SDT applied to health behavior counseling to complement behavioral change
promoted through motivational interviewing (­Patrick & Williams, 2012), which is a
patient-centered approach to help individuals develop motivation to change a behavior
(Miller & Moyers, 2007).
FIGURE 7.3  Social determination theory as it applies to healthy
dietary behavior change (Patrick & Williams, 2012).
External
regulation
Behaving for
reward or
to avoid negative
contingency
Eating healthy
to win a prize
or stay employed
Eating healthy
because food
choices reflect
one’s character
Eating healthy
because it is
an important
personal goal
Eating healthy
because it is
consistent with other
health goals
Behaving out
of guilt,
obligation,
need to prove
Behaving
because of the
importance
ascribed to
the behavior
Behaving because
behavior is
consistent with
other goals and
values
Introjected
regulation
Identified
regulation
Integrated
regulation
146	III. Lifestyle Change/Disease Prevention Interventions
Transtheoretical Model: Stages of Change
The Stages of Change Model for dietary behavior change has been employed in several
dietary intervention studies. This model suggests that behavior change involves
a sequence of “events” or stages that build toward sustained behavioral change. These
stages include: (1) pre-contemplation during which a person is not aware, has not
considered, or may be in denial about the needed behavior change, (2) contemplation
wherein something happens to increase awareness and while there is some ambivalence
regarding the dietary behavior change the person now has an awareness of the need for
change, (3) preparation or the point at which the person actively gathers information
to assess the costs and benefits of behavior change, followed by (4) action wherein the
behavior is now being practiced using prior experiences, information, new skills, and
motivation, and finally, (5) maintenance during which the dietary behavior is now practiced
consistently and is somewhat habitual. The Stages of Change Model is sometimes
applied to screen patients for eligibility in interventions or dietary change programs
wherein individuals must be at the contemplation or preparation stage to be considered
for program entry.
Theory of Diffusion of Innovations
While this theory is not solely applicable to dietary change, it does have a clear application
in this context. This theory notes that behavior change is about the compatibility of
the innovation with an individual’s economic, sociocultural, and philosophical values.
Several factors influence the adoption of the new behavior including the complexity,
flexibility, relative advantage over current methods, cost-efficiency, and risk. Diffusion
of Innovations Theory suggests that people fall into categories such that some can be
described as innovators, those who develop new approaches, others are early adopters
of the innovations, the majority adopt the behavior once the innovation is more diffused
within the culture, and finally laggards are those who are resistant to the innovation.
This theory probably has its greatest relevance to the use of e-technologies to promote
dietary behavior change. Knowing an individual’s “category” related to new technologies
will help to determine the most appropriate plan for integrating innovations into
behavior change strategies. For example, a patient/client who is resistant to writing
down their daily food intake to self-monitor may be challenged and excited by the use
of a smartphone application to achieve the same goal. Being aware also will ensure
greater adherence. For example, if a patient is instructed to cook vegetables in the microwave
and they have yet to adopt the microwave as a cooking method, they may not
adapt your advice to another cooking technique and instead not eat the vegetables. In
the end, they are unsuccessful in achieving the eating behavioral goal.
BEHAVIORAL APPROACHES TO PROMOTION OF DIETARY CHANGE
Goal Setting
Goal setting is an important component of dietary behavior change. Goals can not
only provide the necessary clarity regarding the structure, specificity, and expected
outcomes, they also support self-efficacy over time. Goal setting should include both
short- and long-term goals. Short-terms goals, if achieved, should promote the eventual
achievement of long-term goals as well. Short-term goals need to be specific to be effective
in promoting the desired behavioral change and generally are written with the
patient/client in an effort to individualize the goal to address barriers identified that
	 7.  Dietary Behaviors: Promoting Healthy Eating	147
may hinder a person’s success in achieving a goal. For example, a short-term goal to eat
vegetables every day is unlikely to be successful if the patient has reported that there
are no available vegetable options to eat at work. Instead the short-term goal should be
developed to address this barrier to dietary behavior change and could be revised to,
“I will eat two servings of vegetables during each work day which I prepare at home
and take with me to work. These will include raw carrot or celery sticks that I keep at my
desk, a salad I prepare, or if not a leftover vegetable dish from dinner that I will reheat
in the break area microwave at lunch time.” This level of specificity promotes behavior
change in a way that is achievable within the individual’s “influences” on dietary decision
making. Goal setting is most effective when accompanied with self-monitoring.
Self-Monitoring
Self-monitoring in the context of diet is the act of recording a specific dietary behavior
on an ongoing basis. The value of self-monitoring lies in repeated awareness or cues for
healthy decisions. However, the recorded information must align with the short- and
long-term goals that have been set. For example, recording of all foods consumed may
be relevant when energy intake goals have been set for weight loss, but may overburden
patients and have less relevance when the target behavior is reduced sodium intake for
blood pressure control. In this situation, having individuals record sodium content from
labels of foods consumed and/or use of salt shaker/packets may have more relevance
and thus be more acceptable and sustainable for self-monitoring behavior. Components
of eating behavior that are frequently self-monitored for diet change include not only
tracking of overall diet and specific nutrients (sodium, fiber, fat, fruit, and vegetables),
but also meal spacing, location, timing, rate of eating, and stimulus control.
Self-monitoring can be challenging to initiate and matching the approach to the
individual can facilitate success in this area. For example, a younger patient with a
smartphone may wish to use applications (apps) to record intake and may find the
immediate evaluation of outcome (sum of sodium intake throughout the day) motivating
to continue self-monitoring and yet would have resisted writing down all foods
consumed in a diary format. The frequency of self-monitoring also is important. General
practice is to recommend that dietary monitoring be completed daily at least in
the initial change period (6–12 weeks). After this point, self-monitoring frequency may
be reduced without marked recidivism in behavior, but should not be eliminated as
a behavior change strategy all together. Self-monitoring also should be increased in
frequency and adjusted in context as new barriers to change are identified and new
approaches to achieving long-term health goals are set. Self-monitoring has been consistently
associated with weight loss, although there is a lack of evidence in diverse
populations as well as objective measures of adherence to self-monitoring protocols or
estimates of “dose” required to achieve weight loss (Burke, Wang, & Sevick, 2011). Of
note, advances in electronic monitoring of eating and lifestyle behaviors suggest new
electronic approaches, particularly when combined with daily feedback messages, may
improve adherence to self-monitoring and thus indirectly result in greater achievement
of dietary behavior change goals ( Burke, Conroy et al., 2011; Burke et al., 2012).
Group Support
Support is an important factor for behavior change as well as for increased duration
of change over time. Support may be in the form of groups as has been commonly
employed in several long-term dietary trials requiring substantial dietary change
including the Women’s Health Initiative Dietary Modification trial (Anderson et al.,
148	III. Lifestyle Change/Disease Prevention Interventions
2003), the PREDIMED trial (Zazpe et al., 2008), and the Look Ahead trial (Ryan et al.,
2003). Attendance at group sessions also has been associated with greater adherence to
dietary goals (Tinker et al., 2007). There is also evidence that group counseling may be
more effective than phone-based counseling of individuals for weight control (Befort,
Donnelly, Sullivan, Ellerbeck, & Perri, 2010).
Beyond group support, perceived support from clinic or study staff throughout trial
participation also has been shown to promote greater change in eating behaviors mostly
related to enhanced self-efficacy and to promote eating behavior change. Frequency and
quality of contact as well as extended duration of contact each may have independent
effects on dietary behavior change and both appear to be integral to achievement and
maintenance of dietary behavioral goals (Middleton, Patidar, & Perri, 2012; Turk et al., 2009).
Additionally, Perri and colleagues have evaluated social support for healthy behaviors
and identified an important role for friends and family. This work suggests that family and
friend support is associated with greater success with weight loss (Kiernan et al., 2012).
Problem Solving
Behavioral approaches to dietary change generally address the issue of problem solving
early in the counseling process. The important issue here is for the patient/client rather
than the clinician to identify problems. This is important if there is to be ownership of
the short-term goals required to address the problems as identified. Problem solving
requires the use of both cognitive and behavioral techniques and not only addresses
the person’s perceived barriers to behavior change, but also their prior or planned
approaches to overcome these barriers to promote the achievement of dietary goals.
The discussion may begin with an open listing of barriers followed by a review of usual
daily activities around food that may help to identify additional barriers. Developing
a diagram of the behavior chain surrounding food choices can help the patient/client
to identify barriers that are not as readily apparent without reviewing a typical day’s
activity and how these may inform eating choices. Figure 7.4 provides an example as to
how a behavior chain might be developed in conversation with the patient/client.
Skip
breakfast
Hungry;
vending
pretzels
lunch
Late lunch
salad; work-
related
stress; eat
chocolate
Eat prepared
meal as
planned
Starving and
bored by 7 p.m.;
pull out the
ice cream
Eat ½ carton;
feel
defeated
Once home
jump on
treadmill for
20 minutes
Guilty; stop
and buy low
calorie
frozen
dinner
FIGURE 7.4  Food behavior decision making: Identifying barriers to change.
(Adapted from Foster et al., 2005)
	 7.  Dietary Behaviors: Promoting Healthy Eating	149
Once barriers have been identified, a discussion will commence to identify not only
approaches previously employed that were successful in promoting healthy eating, but
also to define and describe with specificity new strategies that the patient/client identifies
as adoptable for use in meeting dietary behavioral goals. The role of the counselor
is to facilitate the identification of barriers as well as change strategies. Problem solving
is not a stand-alone technique but rather is generally applied within a larger behavioral
plan to promote dietary change.
Motivational Interviewing
Motivational interviewing is perhaps the most commonly employed strategy to dietary
behavior change. Several companies have been established in recent years to address
the need for enhanced training of health care providers on this approach. It is incorrect
to assume one can use motivational interviewing to effectively help patients/clients
change eating behaviors without ample training on the topic. Motivational interviewing
is a collaborative, person-centered form of guiding individuals to elicit and strengthen
motivation for change (Miller & Moyers, 2007). Motivational interviewing helps individuals
identify and resolve ambivalence with behaviors targeted for change and
centers on motivational processes that facilitate the desired change. Motivational interviewing
(2012) by nature is a conversation between the patient/client and the health
care provider that honors autonomy and is evocative (www.motivationalinterviewing.
org). An effective motivational interviewing interaction has been described to include
eight tasks: openness of discussion, proficiency in client-centered counseling, identifying
change and sustain talk, eliciting and strengthening change talk, reflectively hearing
sustain and resistance talk, recognizing readiness toward development of a change
plan, consolidating commitment, and transitioning and blending motivational interviewing
techniques with other effective behavioral approaches and strategies (Miller &
Moyers, 2007).
Technology and E-Strategies for Dietary Behavior Change
Thewealthofnewinnovations,apps,anddevicesfordietaryassessment,­self-monitoring,
and behavior change has presented new challenges in dietary behavior change. The
theoretical model that has the most relevance here is likely the Diffusion of Innovations
Theory although several studies using these methods also report use of Social
Cognitive Theory, Transtheoretical Model and Precaution Adoption Process (­Norman
et al., 2007). Whether current health ­behavior models will have validity in relation to the
increasingly interactive and adaptive mHealth approaches remains to be determined
(Riley et al., 2011).
Overall there is limited but growing evidence as to the degree of behavioral change
that can be achieved using technological approaches. Less is known about how sustainable
dietary behaviors are when they are achieved with the support of ­e-technology.
Evidence does show that significant changes in dietary behavior, including those associated
with weight loss can be achieved without face-to-face contact between participants
and weight loss providers (Appel et al., 2011). The lack of comprehensive evidence
should not be perceived as lack of efficacy. In reality, several studies have been completed
to evaluate the degree of behavior change that can be realized, although the
best methods for delivery, best devices to be employed, dose, and duration have yet
to be defined. A review by Norman and colleagues in 2007 identified 7 diet interventions
using mHealth and 11 weight loss interventions (Norman et al., 2007). Table 7.2
150
TABLE 7.2 Select Studies Using e-Health Technology to Effectively Promote Dietary Behavior Change
STUDY LEAD INVESTIGATOR TECHNOLOGY OR
PLATFORM
TARGET BEHAVIOR TARGET POPULATION
Carpenter, Finley, & Barlow,
2004
Interactive website Healthy Eating Index score N = 98; middle-aged, predominantly
Caucasian females
Stevens, Glasgow, Toobert,
Karanja, & Smith, 2003
Website Dietary fat intake N = 616; age 40–70 y; overweight/
obese females
Nollen et al., 2013 Handheld computer
program
Fruit and vegetable intake N = 15 ; age 8–15 y; females only
Oenema, Tan, & Brug, 2005 CD-ROM Fruits, vegetables, and fat N = 616; middle-aged males and
females, worksite-based
Baranowski, Baranowski, &
Cullen, 2003
Computer games Fruit and vegetable intake N = 1578; children aged 8–12 y
Anderson, Winett, Wojcik,
Winett, & Bowden, 2001
Grocery store kiosk Dietary fat, fiber, fruits, and
vegetables
N = 277; greater than 97% Caucasian
adult females
Newman et al., 2005 Interactive telephone Dietary fat, fruits and
­vegetables, and fiber
N = 3088; female breast cancer
survivors
Irvine, Ary, Grove, &
­Gilfillan-Morton, 2004
Interactive multimedia Fruit and vegetable and fat
intake
N = 517; middle-aged, predominantly
Caucasian females at worksite
Spring et al., 2012 Telephone coaching
plus mobile decision
­support technology
Fruit and vegetable intake,
­saturated fat and caloric
intake; sedentary time
N = 204; adults with low scores on
healthy lifestyle behaviors
Block et al., 2008 e-mail lifestyle
­intervention
Fruits and vegetables, saturated
fat, added sugars, physical
activity; self-efficacy, stage of
change
N = 787; age 19–65 y; 95% female;
majority Caucasian
	 7.  Dietary Behaviors: Promoting Healthy Eating	151
lists select dietary ­intervention trials that employed a variety of e-health technological
approaches to effectively promote diet and/or lifestyle behavior change.
As suggested in the table, earlier studies focused primarily on the use of telephonebased
counseling and CD-ROM delivery of information. More recently, efforts are ongoing
to expand to smartphone applications and game-based multi-modality interventions
to promote behavior change; however, there is a paucity of research providing comparative
effectiveness between the methodological approaches employed. There is also the
challenge of a rapidly changing technological environment in relation to available apps,
devices, and delivery systems, such that by the time a study is complete and reported in
the literature, new more novel and perhaps more easily implemented devices and apps
may be available. Further, across cultural, gender, education, and age groups adoption
of individual devices and apps can vary widely not only in relation to apps commonly
used but also to the frequency of use and time to full adoption. These factors challenge
the external validity of the research being done to evaluate e-technology for behavioral
change.
Promoting Healthy Eating Behavior: The Clinical Setting
In addition to individual and group specific counseling efforts designed to support
healthy eating choices, the clinical environment can serve as an additional reinforcement
for patients and clients. First and foremost efforts by health care providers must
receive adequate training on the importance of diet in health as well as effective methods
to promote improvements in eating behaviors. Yet, deficiencies in current training
programs continue to be identified (Vitolins et al., 2012). Providers also must develop
competence in addressing eating behaviors with their patients/clients and avoid disparagement
of those who report lower quality diets or who are obese, a common and
generally socially acceptable prejudice in our health care system (Wolf, 2012; Teixeira,
Pais-Ribeiro, & Maia, 2012). Empathy in encounters is central to meaningful interactions
toward change in eating behaviors. Health care providers should ask patients their own
perceptions about their weight or dietary behaviors and build from the response, affirm
the difficulty in making and sustaining changes in eating behavior, and listen carefully
using a patient-centered approach.
Beyond developing an empathetic initial encounter, the physical office can be modified
to deliver an attitude of empathy, education, and self-empowerment. First, evaluate
the clinic in relation to physical attributes (e.g., room to wait comfortably, chairs without
arms, scales that are capable of weighing morbidly obese patients, examination gowns
that fit all sizes, and use of large blood pressure cuffs). Second, provide access to relevant
educational resources (healthy food choice/behavior pamphlets, websites, diet
assessment/monitoring applications for e-health, posters on the clinic walls promoting
healthy food, and even an office policy to restrict unhealthy food and beverages
in the clinic setting). Third, provide clinic staff the opportunity, support, and recognition
for advancing their skills in behavioral counseling to support patients who select
to undertake change in eating behaviors. Consider having clinic staffs adopt dietary
behavior change personally so as to gain empathy and experience with the process.
Finally, understand and communicate the importance of realistic expectations.
Finally, routine integration of healthy lifestyle promotion into health services is
needed if we are to succeed in improving the health of the population. Strategies should
engage the health care providers, managers, researchers, and patient representatives
using a socio-ecological model wherein the health care system is actively partnered,
individual behavior change is supported, and educational limitations are overcome in
an effort to achieve optimal dietary health (Grandes et al., 2008).
152	III. Lifestyle Change/Disease Prevention Interventions
CONCLUSIONS
Changing dietary behaviors is challenging. Numerous factors contribute to every food
choice including what, how much, when, and why we choose to eat. Complicating the
matter more is that eating is a required behavior. Thus the decision must be repeated
several times a day throughout a person’s life; abstinence, employed for behavior modification
of tobacco, drugs, or alcohol use, is not generally plausible except perhaps in
relation to individual food omissions in the diet.
Current evidence suggests that clear and specific goals that are patient/client-­
identified and defined, as well as self-monitoring of the behavioral goals established,
are a necessary component of any successful change in eating behavior. These goals
must be complemented with clear antecedents to provide clients with the “how to” for
successful eating behavior change in the context of their individual life circumstances.
Additionally, relapse prevention and recovery is an essential phase in any long-term
plan for sustained eating behavior change.
Promoting healthy food choices and related eating behaviors for patients/clients is
critical to reducing obesity, obesity-related chronic diseases, and a variety of other clinical
diagnoses. Despite the challenges, when patients are able to change eating behaviors
to healthier choices there is a clear benefit that translates to numerous disease-specific
outcomes.
To summarize:
●● Changing dietary behavior is complex and requires long-term, dynamic approaches
and strategies.
●● No one behavioral theory works best; theories should be adapted for the individual
intervention and/or patient/client.
●● Patient-centered counseling including motivational interviewing is perhaps the
most tested and effective strategy for dietary behavior change to date, but many
providers lack sufficient training to effectively apply, for example, motivational
interviewing in practice.
●● To promote change in dietary behavior, clinicians should help clients set clear and
specific goals, promote self-monitoring, recognize the role of social support and use
it to enhance change in eating behavior, review the mechanisms for behavior and
behavior change (antecedents), and focus on preventing relapse.
●● Efforts to identify and determine “best practice” regarding behavioral theories,
constructs, and strategies to help patients/clients improve dietary behaviors need to
be continued.
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