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TAILORED NUTRITION EDUCATION USING THE
STAGES OF CHANGE MODEL TD DECREASE
THE INTAKE OF DIETARY FAT

Schotarly Proiect for the Degree of M. S.
MICHIGAN STATE UNIVERSITY
AMY J. WEBSTER;
1997

 

 

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_ _———

TAILORED NUTRITION EDUCATION USING THE STAGES OF
CHANGE MODEL TO DECREASE THE
INTAKE OF DIETARY FAT

By

Amy J. Webster

A Scholarly Project

Submitted to
Michigan State University
in partial fiflfillment of the requirements
for the degree of

Master of Science

College of Nursing

1997

ABSTRACT
TAILORED NUTRITION EDUCATION USING THE STAGES OF
CHANGE MODEL TO DECREASE THE
INTAKE OF DIETARY FAT
By
Amy J. Webster

Various studies have shown a causative link between diets high in fat and
cardiovascular disease. There is also an association between obesity, stroke, cancer of
certain types, diabetes mellitus and diets that are high in fat content. Because of the
personal and financial burdens of these chronic diseases, the recommendation has been
made to decrease dietary intake of fat from the current 37% to 30% or less of the total
energy intake.

Recent literature has shown a lack of public awareness about the concept of
dietary fat. This finding, along with studies that demonstrate that our current nutritional
educational practices are deficient, is attributed to the American population’s high dietary
fat intake. Traditional nutrition education has centered on the individual who has already
decided to make changes in his or her life. This type of material may be inappropriate for
those not ready to act. I

The Stages of Change Model was used to formulate a nutrition education protocol
to be used by the Advanced Practice Nurse in Primary Care that focuses on individuals in
the early stages of change they are unaware or underaware of a problem. This nutrition
education protocol is designed to facilitate dietary behavior change from the
precontemplation and contemplation stages of change to the preparation stage of dietary

change for the individual over 18 years of age.

This is to certify that the

scholarly project entitled

TAILORED NUTRITION EDUCATION USING THE STAGES OF
CHANGE MODEL TO DECREASE THE
INTAKE OF DIETARY FAT

presented by
Amy J. Webster

has been accepted towards fulfillment
of the requirements for

Master of Science degree in Nursing

V ltd—ajor Professor

Date HIALL/ {7

I

To my loving husband.

iii

ACKNOWLEDGMENTS
I would like to pay a special thanks to Ann Melon, Registered Dietitian. As a
professional practicing in the community, she offered her time and expertise during an
independent study in the area of nutrition education, sparking my interest in the Stages of
Change Theory. She has been an excellent source of knowledge about the process of

dietary education. I would also like to thank my fiiends and family for their support while

pursuing my professional goals.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................................. vi
LIST OF FIGURES ............................................................................................... vii
CHAPTER 1
INTRODUCTION ................................................................................................. 1
CHAPTER 2
LITERATURE REVIEW ....................................................................................... 4
The Impact of Diet on Health ...................................................................... 4
Public Knowledge, Attitudes, and Behavior of Dietary Fat Intake ............... 5
Issues of Health Promotion ......................................................................... 7
The Nurse Practitioner and Dietary Education ............................................. 8
CHAPTER 3
THEORETICAL FRAMEWORK ......................................................................... 11
Stages of Change ........................................................................................ ll
Processes of Change ................................................................................... 13
Stages of Change and Dietary Fat ............................................................... l6
Validation of the stage of change algorithm .................................... 16
Dietary intervention using stage of change ....................................... 21
Demographics ................................................................................. 22
CHAPTER 4
SCHOLARLY PROJECT PROTOCOL ................................................................. 25
Nutrition Education .................................................................................... 25
Steps 1 & 2: Assessment ................................................................ 25
Step 3: Intervention ........................................................................ 26
Nutrition Education Evaluation / Research .................................................. 28
CHAPTER 5
IMPLICATIONS FOR ADVANCED NURSING PRACTICE ............................... 31

LIST OF REFERENCES ....................................................................................... 34

LIST OF TABLES

Table l - Processes of Change: Definitions and Interventions ................................. 17
Table 2 - Stages of Change Where Processes of Change Occur ............................... 18
Table 3 - Staging Questions for Dietary Fat Reduction ............................................ 32 .
Table 4 - Staging Algorithm Scoring ...................................................................... 33

Table 5 - Food Frequency Questionnaire ................................................................ 34

LIST OF FIGURES

Figure l - Spiral Model of the Stages of Change ..................................................... 14

vii

Chapter 1
INTRODUCTION

An important topic in research and education has been the relationship between
decreasing dietary fat intake and reducing the risk of ch ronic disease. High fat diets have
not been shown to have a causal relationship in such diseases as obesity, diabetes mellitus,
heart disease, stroke, and certain types of cancer. However, evidence supports that dietary
fat intake has major contributions in the development of these chronic diseases, raising the
potential for increased morbidity and mortality (Bernstein, 1985; Greenwald & Sondik,
1986; Lissner, Levitsky, Strup, Kalkwarf & Roe, 1987; Rifkind, 1984; U. S. Department
of Health and Human Services [U.S. DHHS], 1984, 1988, 1992 ). Despite the efi‘orts of
nationwide programs to decrease dietary fat intake to combat the lmown adverse efi‘ects of
these chronic diseases, Healthy People 2000 reports that dietary fat intake remains at 37 %
of total energy intake. The DHHS has called for more effective nutrition education to help
reduce society’s fat consumption from the current intake down to less than or equal to
30% of total energy intake (U. S. DHHS, 1992).

Nutrition education has traditionally centered on the individual who has already
decided to make changes in his or her life and is involved in seeking out information in
order to carry this out (Campbell, DeVillis, Strecher, Ammerman, DeVillis, & Sandler,
1994; Curry, Kristal & Bowen, 1992; Greene, Rossi, Reed, Willey, & Prochaska, 1994;
Prochaska & DiClemente, 1992). This type of educational material may be inappropriate
for those not yet ready to act. Researchers have found that traditional methods of

intervention focus on the person during an action stage, or one in which the person is

already committed and involved in changing their behavior. These methods do not work
with persons who are not aware of a problem or who have not yet committed to change.
Prochaska attributes inappropriate education methods to the continued poor statistics
related to dietary health (Prochaska et. al., 1992).

Recently, the Transtheoretical Stages of Change Model is being used in
conjunction with nutrition education to facilitate more effective dietary behavior change.
The model describes how people change on their own and states that the modification of
various behaviors progress through six specific stages, allowing for researchers to develop
educational material targeted for specific stages (Campbell et al, 1994; Gray et al., 1992;
Greene et aL, 1994; Prochaska et. al, 1992; Prochaska & DiClemente, 1992).

The goal of this paper is to present a three-step nutrition education protocol for
the advanced practice nurse in primary care. The first and second steps involve assessing
a person’s eating behavior, and identifying the stage of behavior change the person is in.
The final step is an early stage of change educational intervention tool, based on current
nutrition education methods. This educational protocol is designed to be an integral part
of the advanced practice nurse’s approach to health promotion, as dietary behavior has
been associated with chronic diseases causing some of the highest rates of morbidity and
mortality in the United States. The expected outcome of the nutrition education module is
to help prepare the client to facilitate him or herself to move from the early stages of
dietary behavior change to the mid and later stages by using educational techniques

specific for the stage of change the client is in.

The Transtheoretical framework was applied to dietary behavior, providing
research which demonstrates that individuals move through the stage of behavioral change
while decreasing dietary fat intake (Prochaska et al., 1992; Prochaska & DiClemente,
1992; Prochaska et al., 1994). Only a few programs have used this research to develop
interventions which are targeted toward an individual’s current dietary stage of behavior
change to reduce dietary fat intake (Campbell et al. 1994; Spomy & Contento, 1995).
Unfortunately, there is no documentation to date on how the advanced practice nurse
(APN) is using these research results and education techniques specifically to decrease
dietary fat intake, promoting health in the primary care setting.

Research indicates APNs use protocols to change dietary intake for the obese,
diabetic, elderly, and pediatric clients. However, these protocols are developed within a
secondary prevention fiamework, as opposed to a primary prevention fiamework.
Investigators strongly urge continued research to evaluate the impact of tailored education
with the stage of change model to decrease dietary fat intake, lowering a persons risk for
disease (Campbell et aL, 1994; Curry et aL, 1992; Greene et al., 1994; Prochaska &
DiClemente, 1992). The Advanced Practice Nurse has the abilin to extend the study of
tailored dietary education by implementing tailored nutrition education to decrease dietary

fat intake using the stages of change model.

Chapter 2

LITERATURE REVIEW

The Ianact of Dietary Fat on Health

 

Diet-related illnesses inflict a substantial burden, both personal and financial, on the
American population. High intake of total dietary fat is associated with cardiovascular
disease, an increased risk for obesity, some types of cancer, and diabetes mellitus
(National Institutes of Health [NIH], 1984, 1985; US. DHHS, 1988). Studies have
shown that reducing dietary fat intake to less than or equal to 30% of total energy delays
manifestations of atherosclerosis and ischemic events by a reduction in plasma cholesterol.
This dietary change reduces the risk for morbidity and mortality from cardiovascular
disease, and diseases which are related to the cause of cardiovascular disease. (Institute of
Medicine, 1991; Judd, Clevidence, Muesing, Wittes, Sunkin, & Podczasy, 1994;
Marckmann, Sandstrom, & Jespersen, 1994; Rifkind, 1984; U. S. DHHS, 1988). These
results, which impact the financial and personal burdens related to these diseases, have led
experts fiom across many disciplines to make the recommendation nationwide to decrease
dietary fat intake to less than ‘or equal to 30% total energy. (Beynen.& Katan, 1989;
Fortman, Williams, Hulley, Haskell, & Farquhar, 1981; Greenwald & Sondik, 1986;
Harlan & Stross, 1985; Heine & Schouten, 1989; Institute of Medicine, 1991; Judd,
Clevidence, Muesing, Wittes, Sunkin, & Podczasy, 1994; Marckmann, Sandstrom, &

Jespersen, 1994; NIH, 1984; Rifldnd, 1984; U. S. DHHS, 1988).

Public Knowledge. Attgitudesgand Behavior of DieLary Fat 1mg;

It is well known that the nation’s dietary fat intake remains well above the targeted
less than 30% goal, despite the known health risks involved (U. S. DHHS, 1988, 1992).
Although public awareness of the relationship between diet and health has increased, on
average, people’s knowledge and understanding of the in-depth concepts remain limited.
For example, in a study assessing public understanding of cholesterol and heart disease,
only one-half of the individuals knew that saturated fat comes mainly fiom animal sources,
polyunsaturated fats from plant sources, or that cholesterol and fat are difi’erent
(Schucker, Bailey, Heimbach, Mattson, Wittes, Haines, Gordon, Cutler, Keating, Goor &
Riflrind, 1987). Auld, Achterberg, Durrwachter & Novak’s (1991) study to assess gender
difl‘erences in knowledge about fat and cholesterol found that, overall, both men and
women had a very limited knowledge about fat and cholesterol, scoring only 25% of the
possible points before exposure to an informational bulletin about the subject. Their study
revealed that individuals did know common information easily accessed through the
media, for instance, they knew that fat and cholesterol intake are related to heart disease.
They also knew that there are difi‘erent types of fat and cholesterol, some better and some
worse for one’s health. Neither the men nor women involved in this study were likely to
know the specific information needed to reduce the risk of heart disease (Auld,
Achterberg, Durrwachter & Novak, 1991).

Greidanus & Contento (1989) support the findings that individuals have a limited
knowledge about fat and cholesterol, as they have concluded in their studies that

attempting to decrease the amount of total dietary fat intake to 30% involves complex

cognitive components, besides a basic understanding about fat. Knowledge about food
composition, cognitive skills to analyze food and nutrition information, proper food
selection ability, and food preparation skills are all involved in attempting to consume a
diet composed of less than or equal to 30% fat.

Despite the research depicting the relationship between eating diets high in fat and
the risk of disease, only 14% of individuals are eating diets less than or equal to 30% of fat
of their total energy intake ( Murphy, Rose, Hudes, & Viter, 1991). Dietary behavior is
highly complex, involving not only nutrition knowledge, but other factors, such as
personal attitude toward diet, perceived control, and perceived societal norms which
impact the individual in the type of diet consumed (Bowen, 1992; Kristal, Bowen, Curry,
Shattuck, & Henry, 1990; Spomy & Contento, 1995). In a study to explore the domains
of nutrition knowledge and attitudes about diet and perceived norms in selecting diets low
in fat, investigators found general knowledge about the relationship between nutrients and
cancer risk did not affect dietary behavior (Kristal, Bowen, Curry, Shattuck, & Henry,
1990). However, practical knowledge, or the ‘how to’ in selecting a diet low in fat, was
strongly related to whether the diet was high or low in dietary fat. Researchers suggest
that the “how-to” in selecting foods low in fat, or the specific food choice information is
required in an environment that ofi‘ers a large selection of high fat foods, in order for the
individual to be successfirl in decreasing fat intake (Kristal, Bowen, Curry, Shattuck, &
Henry, 1990.) General information on types of fats or food content becomes confusing to

the consumer.

Perceived societal norms, positive or negative beliefs about dietary behavior, have
an impact on dietary attitudes. Researchers have illustrated that perceived societal norms
have the strongest impact on dietary behavior. Furthermore, studies have found that there
is a very low social stigma to eating high-fat foods. These researchers hypothesize that
this may be due to the fact that reductions in fat intake do not lead to immediate
observable physiologic changes (Kristal, Bowen, Curry, Shattuck, & Henry, 1990;
Spomy & Contento, 1995). They go on firrther to state that fat content is a very abstract
concept for individuals to. grasp, as it is not an observable concrete object. (Kristal,

Bowen, Curry, Shattuck, & Henry, 1990; Spomy & Contento, 1995).

I_s_sues of Health Promotion

A 1983 study on health promotion involvement by primary care physicians found
that less than half of the primary care physicians studied regularly gather information fiom
patients about diet, exercise, or stress (Wechsler et. al., 1983). Russel & Roter (1993)
looked at health promotion counseling of chronic-disease patients in primary care by
reviewing audio tapes of visits. They found 43% of visits included some discussion about
diet or weight control, the most fiequently mentioned lifestyle discussion. However, the
study included any mention of the patient’s diet or need for change whether it was topics
on weight control, sodium, fat, or cholesterol. As the investigators dissected the sessions
according to intensity of counseling, they found only 6% of the time extensive counseling
was performed on health promotion topics, and the majority, approximately 54% of the

counseling sessions involved a brief mention, brief advice, or brief counseling.

In examining health promotion, education, and counseling activities performed by
nurse practitioners, Brown & Waybrant (1988) found nearly 83% of NPs engaging in the
discussion of general nutrition information in at least one client each day. The average
number of patients per nurse practitioner receiving general nutrition information was
between 3 and 4. Approximately 42% of the visits involved health promotion in the area

of nutrition education, obesity, or weight control education. (Brown & Waybrant 1988).
The Nurse Practitioner and Dietary Education

Nurse researchers have developed nutrition assessment and intervention protocols
for the Advance Practice Nurse’s use in pediatric, elderly, diabetic, and overweight and
obese populations in primary care (Franz & Reader, 1991; Melkus, 1994; Mion,
McDowell, & Heaney, 1994; Schreiner & Brondum, 1994). All of these protocols
include a 24-hour food recall or food-frequency questionnaire, anthropometric
measurements and laboratory analysis. The nutritional assessment of the elderly and the
assessment of the overweight and obese cheats also have psychological, economic, and
family history components included in their assessments (Melkus, 1994; Mion et al,
1994; Rosenblett, 1989). Interventions follow a common theme of identified needs
deficits in the realms of the individual through the assessment protocols and setting
mutually agreed upon goals between the client and the APN. Interventions to increase
nutritional adequacy were found to be toward deficits in the physical, physiological,
psychosocial, and economic realms of the individual, based on US. recommended daily

allowances and calorie requirements found in the assessment.

These approaches to nutrition education, assessment, and intervention demonstrate
reactionary programs to reverse disease, not methods to prevent disease. The protocols
consistently illustrated assessments such as weekly food recalls, 24-hour diet recalls, and
laboratory analysis. These can be very time consuming and expensive methods to respond
to disease (Kristal, Shattuck, Henry, & Fowler, 1990; Medlin & Skinner, 1988). The
APN is doing very little in assessing and facilitating behavioral change for disease
prevention, specifically for individuals at risk due to diets high in fat. Advanced Practice
Nurses in primary care have the opportunity to incorporate a more preventative approach
by assessing those at risk for disease and intervene to change dietary behavior. Methods
and interventions already formulated in the protocols reviewed above, combined with
current theories of behavior change, can be an efi‘ective way to decrease health costs at

both individual and national levels.

In summary, America’s dietary fat intake remains too high at 37% total energy
intake as opposed to the targeted goal of 30% or less total energy intake, placing
individuals at serious risk for disease. Curbing the financial, psychological, physical, and
emotional costs of chronic disease affecting both the individual and society, is currently
becoming a driving force in the nation’s health care system. The studies reviewed above
show that Americans are underaware of the impact of a high fat intake and the health risks
involved in eating a diet that is composed of 37% fat. Studies also demonstrated that
current methods of health promotion in regards to dietary fat intake are inefl‘ective. All
these are attributing factors to the continued dietary intake of 37% total energy.

Therefore, the nurse practitioner in primary care has the opportunity to play an important

lO

role in helping patients reduce dietary fat intake. As studies have shown, a reduction in
dietary fat intake reduces the risk for certain chronic diseases. A reduction in dietary fat
intake facilitated through nutrition education, can be a cost saving approach to today’s

health care.

 

Chapter 3
THEORETICAL FRAMEWORK
mastheoretical Model of Behavior Chairga

Stages of Change. Prochaska’s study of self-attempts at stopping addictive
behaviors led to the finding that change involved a transitional process with specific
cognitive constructs. Self-eflicacy, locus of control, barriers and facilitators to change,
reinforcers and punishers in change, cues and consequences, and societal norms were
identified as having an efi‘ect on the individual to change. Prochaska’s study of change in
other high risk behaviors revealed that individuals consistently follow a stable pattern of
transformation in which specific processes or behaviors, emotions, and actions, are
identifiable at each stage. This model assumes a focus on the person’s intention to change
in addition to their perceptions of the risks and benefits to change. (Prochaska, 1989;
Prochaska & DiClemente, 1992; Prochaska et al., 1992). Prochaska has identified the six
stages of behavior change as shown in Figure 1: precontemplation, contemplation,
preparation, action, maintenance, and termination.

Precontemplation is the earliest stage identified in which the individual is unaware,
underaware, and is not interested in changing within the next 6 months. They may have
experienced few negative side} effects from the behavior, feel that it is under control, do
not see it as a problem, and may be defensive to social pressure to change. To progress
toward changing the behavior, the precontemplator must acknowledge the behavior as a

problem and increase their awareness of the long-term effects of the behavior. (O’Connell

12

& Velicer, 1988; Prochaska, 1989; Prochaska & DiClemente 1992; Prochaska et al., 1992;
Prochaska et a1, 1994).

Contemplation is the stage in which the individual acknowledges a problem exists
and is seriously thinking about overcoming it within the next six months but does not have
a plan of action. Contemplators are involved in seeking information about their behavior.
They chronically substitute thinking about the change for changing their behavior. These
people would have to make a firm decision to take action and begin formulating a
preliminary plan to change in order to move to the next stage. (O’Connell & Velicer,
1988; Prochaska, 1989, 1992; Prochaska & DiClemente 1992; Prochaska et al., 1992;
Prochaska et a1, 1994).

Preparation is the stage in which individuals are intending to take action in the near
future, usually in the next month. They portray a readiness to change in both attitude and
behavior. They are making firm commitments to change, setting goals and priorities to
meet their commitment. Individuals in this stage typically progress through this state
within six months. (O’Connell & Velicer, 1988; Prochaska, 1989, 1992; Prochaska &
DiClemente 1992; Prochaska et a1, 1992; Prochaska et a1, 1994).

Action individuals are making consistent attempts at behavioral change with the
beginning signs of improvement. These people must have the skills to use key processes
identified as counterconditioning, stimulus control, and contingency management to
interrupt their patterns of behavior (Prochaska & DiClemente 1992). The usual time
fiame for the action stage is usually zero to six months. Individuals in the action stage

need effective strategies to prevent relapse if they are to maintain their goal (Prochaska,

 

13

1989, 1992; Prochaska & DiClemente, 1992; Prochaska et al., 1992; Prochaska et al.,
1994)

Maintenance is defined as the period six months after the goal behavior has been
reached and engaging in the at-risk behavior has finally stopped. This is a period in which
the behavior change is stabilized and attempts are made to prevent relapse. (Prochaska,
1989, 1992; Prochaska & DiClemente, 1992; Prochaska et al., 1992; Prochaska et al.,
1994)

Termination is when the individual has no temptation to engage in the at risk
behavior such as smoking, substance abuse, or eating diets high in fat. Self-efficacy has
been reached against all previously tempting situations (Prochaska, 1992).

Processes of Cha_nga, Ten transtheoretical processes of change were identified in
both self-initiated and therapy-assisted change (Prochaska & DiClemente, 1992;
Prochaska et al., 1992). The processes are comprised of both cognitive and behavioral
coping mechanisms that are used in each stage of change, allowing us to understand how
the shifis in stages of change occur. Each process is a division which incorporates
multiple techniques, methods, and interventions built on other theoretical constructs on
self-motivation, decision making, and self-eficacy. Table 1 presents the 10 processes fiom
Prochaska & DiClemente’s (1992) work in behavior change, included are their definitions
and examples of interventions applicable for each process.

Prochaska & DiClemente (1992) stress that specific processes can be more
significant at difi‘erent stages of change, table 2 demonstrates stages of change in which

particular processes are in effect. Identifying the processes used in each stage allows the

l4

 

Spiral Model of the Stages of Change

Termination

. r:

Marntenance ,g

0

<

Precontemplation Contemplation Preparation
,5

8

T

Precontemplation Contemplation Preparation

 

Figu_re l. The spiral model of the stages of change starts with precontemplation, moving
through a series of attempts, until maintenance and termination is reached. (Prochaska et

a1,1992,p.1104)

15

educator to be aware of which stage the individual is in, yields for customization of
interventions according to the cognitive and behavioral mechanisms that are being used,
and allows for anticipatory guidance in attempting to change behavior (Prochaska &
DiClemente, 1992).

Transtheoretical researchers have identified the Stage of Change Model as a
cyclical pattern of movement using specific processes of transition during each stage of
change. Researchers caution interventionists and clients against discouragement, as it is
likely for clients to recycle several times through the stages before attaining long-term
maintenance. Investigators have determined that effective change depends on engaging
the right processes at the right stage. Stage of Change investigators have identified
significant errors being used in a majority of today’s nutrition education. First, some self-
changers rely mainly on consciousness raising and self-reevaluation while they are moving
into the action stage, processes which are most indicated for the contemplation stage.
These individuals are trying to modify behaviors solely through insight which has been
found to be inefiective in bringing about behavior change. (Prochaska, 1992; Prochaska
& DiClemente 1992; Prochaska et al., 1992). Other changers are depending entirely on
reinforcement management, stimulus control, and counterconditioning; all having their
greatest impact in the action stage of change. A prerequisite of awareness, decision
making, and readiness are a necessity in the contemplation and preparation
stages.(Prochaska, 1992; Prochaska & DiClemente 1992; Prochaska et al, 1992).

Prochaska et al. (1992) attribute faihtre to change the at-risk behavior to the mismatch of

16

stage of change and process interventions. Furthermore, they point out that most
education programs to change behavior are targeted toward the individual in the action
stage of change, making them inefi‘ective for individuals in different stages of change.
These researchers go on to call for research in assessing the stage of a client’s readiness
for change and tailoring interventions accordingly.
Stages of Change and Dietag Fat

Due to the efl’ects that high-fat diets have on disease, research is examining the
process of change as people attempt to modify their diets by decreasing the fat content.
Among healthy people of a normal weight, most diet-related health problems do not
surface with immediate, dramatic symptoms, and what further deters the acquisition of a
healthy diet is an absence of a social stigma to eat a diet high in fat. (Kristal, Shattuck, &
Henry 1990). Dietary behavior modification for disease prevention strongly relies on the
acquisition of knowledge, as the nutrient composition of foods is complex (Kristal,
Shattuck, & Henry 1990). Having an understanding of the impact of dietary fat on health,
the factors that impact dietary selection, and the possibility to have more effective
methods to educate individuals on dietary change through the assessment of their stage of
change, has led researchers to apply the stage model to dietary behavior in healthy
populations (Prochaska 1994, Prochaska et al., 1994).

Validation of the stage. of change algorithm. Curry et al., (1992) used a brief

 

dietary assessment tool along with a stage of dietary change algorithm to determine the

validity of self-reported stage of fat reduction. The algorithm focused on limiting

Table 1

l7

Proceasps of Change: Definitions and Interventions

Process
Consciousness Raising

Dramatic Relief

Environmental
Re-evaluation

Self-Evaluation

Self-Liberation

Stimulus Control

Counter Conditioning

Helping Relationships

Reinforcement
Management

Social Liberation

Definitions and Interventions
Individual becomes more aware of themselves and their
behavior, by seeking: new information, understanding, and
feedback.

Experiencing and expressing feelings about the individuals
problems and solutions; use of role play and grieving losses
is helpful.

Assesses thoughts and feelings about oneself with
respect to one’s environment. A reappraisal of personal
experience of adapting new behaviors.

Considers personal values, visualize doing new behavior and
envision the emotional impact of the behavior change

A conscious choice and commitment to change their
behavior. Possessing a belief one can change. Intervention:
discussion about decision-making techniques and resolution.

Gain control over situations and other causes of behavior.
Includes the development of cues to stinmlate the new
behavior, avoid or counter things that instigate the at risk
behavior, and restructure environment to avoid situations
at risk for the unwanted behavior.

Substituting alternatives for the undesirable behavior such
as relaxation, positive self-statements, or assertiveness.

Utilizes support during attempts to change behavior from
individuals who care about their behavior through
therapeutic alliance, social support, self-help groups.

The person rewards themselves or are rewarded by others
for making changes, with use of contingency contracts,
reinforcement techniques, self-reward.

An increased awareness of alternatives for implementing
behavior changes in their surroundings with empowerment.

 

(Prochaska et al., 1992, p. 1108)

18

Table 2

Stages of Chaage Where Processes of Change Occur

Precontemplation Contemnlation Preparation Action Maintenance

Consciousness raising

Dramatic relief

Environment reevahration

Self-reevaluation
Self-h'beration

Reinforcement management
Helping relationships
Counterconditioning

Stimulus Control
(Prochaska et al., 1992, p. 1109)

l9

consumption of fat as the behavioral description of eating a low-fat diet. Their data
depicts that one can classify individuals according to their stage of dietary fat reduction, as
their stage of change correlated with their results of the dietary assessment. It shows that
those who have tried and believe that they have succeeded in reducing dietary fat, are
indeed eating diets lower in fat. Those who have not been trying and have no inclination
of trying to reduce dietary fat intake, have the highest fat intake.(Curry et a1, 1992). The
results from two samples show that precontemplators consume 38% of calories fiom fat,
contemplators 37.5%, preparers 37.5%, those in action 35%, and maintainers 34%. As
one can see, the average percent of calories fiom fat in the maintenance stage is still
greater than the national 30% or less goal and the authors stress that even maintainers
need intervention. (Curry et al, 1992).

A study funded by the National Cancer Institute assessed the validity of the stage
of change algorithm using difl’erent behavioral criteria for dietary fat reduction with a
dietary assessment tool (Rossi, Greene, Reed, Prochaska, Velicer, & Rossi, 1993). The
study assessed stage algorithms based on four different single behavioral staging questions
on (1) limiting dietary fat intake, (2) avoiding eating high fat foods, (3) eating a low fat
diet, and (4) eating a diet that is 30% or less fat fiom total calories. Results supported
Curry et a1, (1992), showing dietary fat consumption decreased as stage of change
progressed from precontemplation to maintenance. The algorithm with the behavioral

criteria of 30% or less of dietary fat as total intake was found to be unsuitable due to the

20

lack of the subject’s understanding of the term of a diet less than or equal to 30% of
dietary fat intake. The study also discovered that a significant number of individuals
consistently classified themselves in the maintenance stage with intakes greater than 30%
of calories from fat. (Curry et al. 1992)

A large epidemiologic study of (N=17, 12 l), geographically diverse population of
workers examined the association of the stage of change with the dietary intake of fat,
fiber, and fiuits and vegetables (Glanz, Patterson, Kristal, DiClemente, Heimendinger,
Linnan, & McLerran, 1994). Researchers used a firll-length Food Frequency
Questionnaire, developed by Kristal, Shattuck, Henry, & Fowler (1990), as the objective
measurement to validate the stage of change algorithm, rather than a short dietary
assessment tool as in the previous studies mentioned above. Percentages of dietary intake
of fat for individuals in precontemplation was 39.7%, contemplation 39.3%, preparation
39.7%, action 37.4%, and maintenance 31.7%. Results demonstrated that individuals can
be classified into stages of dietary change, and that dietary fat consumption decreases as
stage of change progresses, supporting previous research. Glanz et a1, (1994) conclude
that the method of categorizing individuals into stages of dietary change is a valid model
They state that their results are generalizable only to large samples and self-administered
diet questionnaires, while other studies have validated the use of the stage of change
model with dietary fat using smaller samples with short self-administered diet
questionnaires.

As was identified in these studies, individuals find it difiicult to understand the

concept of eating a diet that consists of a fat intake at or below 30% of energy. Another

21

study has used an dietary fat avoidance algorithm plus a subset of five dietary and
behavioral markers for low-fat intake as the objective criteria to predict fat intake of less
than or equal to 30% and classify individuals into the stage of change model accordingly
(Grs one, Rossi, Reed, Willey, & Prochaska, 1994). With the use of the behavioral
algorithm, they were able to demonstrate the mean percentage of dietary fat in
precontemplation as 39.4%, contemplation 38.7%, preparation 34.4%, action 29.9%,
maintenance 28.5%. The algorithm for fat avoidance demonstrated results similar to
previous studies mentioned above, but the additional behavioral markers classified
individuals more specifically into the 30% or less than criteria within the stage of change
modeL(Greene et a1, 1994).

Qatary intervention using stage of change. Research has continued to take the
dietary fat stage of change results one step firrther. The Partners in Prevention-nutrition
program used the stage of change model to categorized individuals according to their
stage of readiness to modify their dietary fat behavior in primary care settings (Campbell,
DeVillis, Strecher, Ammerman, DeVillis, & Sandler, 1994). After categorizing the
primary care client into the stage of readiness for diet modification, tailored messages at
decreasing dietary fat were given to each individual accordingly. A short l8-item food
fiequency questionnaire was used to assess fat , fiuit, and vegetable intake for the purpose
of continuing to monitor the validity of the stage of readiness to change and to help guide
intervention. The program was designed for self-administration while patients wait for
their physician appointment. The experiment consisted of 3 randomly assigned groups: an

intervention group who received tailored nutrition messages, a comparison group who

22

received traditional non-tailored material, and a control group which did not receive any
nutrition information. The appropriate nutrition information was accessed via computer
program, according to the individual’s stage of change and then sent to the client. The
results of their project showed that participants who were sent tailored messages were
more than twice as likely than those who were sent non-tailored messages to remember
receiving the information. What is most impressive is that at a 4 month follow-up
posttest, participants in the tailored intervention group had reduced their total fat intake
over 10 grams, from 45.6-to 35.3, and their saturated fat decreased by nearly 5 grams.
The non-tailored group did decrease their total fat intake but only by 3.6 grams, a level of
change that becomes less weighty when compared to the tailored intervention group. This
study demonstrates that efl‘ective individualized nutrition information can be provided to
prevent chronic disease in the primary care setting. (Campbell et a1, 1994).
Demoggphics. All of the studies examined above had very similar results.
Surprisingly, a majority of people indicated that they were considering changes in their fat
intake, only about one-third of individuals studied indicated they were in the early three
stages of change, not considering changes, thinking about changing, or planning on change
(Curry et aL, 1992; Glanz et al., 1994; Greene et al., 1994; Rossi et a1, 1993):
Investigators attribute this to the trends in awareness of nutrition. Dietary fat
consumption has been the leading nutritional concern in the U. S. since 1980 (Glanz et al.,
1994). All of the studies demonstrated that those individuals in the precontemplation and
contemplation stages were consuming the most fat and those in the maintenance stage

were eating the least fat (Campbell et al., 1994; Curry et al., 1992; Glanz et al., 1994;

23

Greene et a1, 1994; Rossi et al., 1993; Spomy & Contento 1995). Age, sex, and
education all had an efi’ect on the stage of change an individual was in. Those who were
female, older, and had an education greater than 12 years were more likely to be in the
action or maintenance stages (Campbell et a1, 1994; Curry et al, 1994; Glanz et al.,
1994) . Women, consumed less dietary fit then men and were more likely to be in the
action and maintenance stages of change than men (Campbell et al., 1994; Curry et al.,
1992; Glanz et al., 1994; Greene et a1, 1994; Rossi et a1, 1993; Spomy & Contento
1995). Conversely, men and those with an education of less than 12 years, were more
likely to be in the precontemplation and contemplation stages. Glanz et al. (1994) found
that individuals who were classified as being overweight or obese by their Basal Metabolic
Indexes were less likely to be precontemplators and more likely to be actively attempting
dietary changes to reduce fit intake, than those in the less than average to overweight
categories. The health care provider must be alert to these demographics in the stage of
change for the modification of fit intake, as they may change some misconceptions of the
overweight and non-obese individual These demographics may also help the health
practitioner to be alert to special groups of individuals needing nutrition intervention such
as men, individuals who are less than 35 years of age, and those with an education of less
than 12 years, as they may be more likely to be in the precontemplation stage of readiness
to change and have higher fit intakes.

Spomey & Contento (1995) examined the social psychological variable on dietary
fit reduction with the stages of change. The perceived health status, perceived

susceptibility, and perceived benefits to health were important variables to note for

24

individuals in each stage of change. Individuals in the contemplation stage had the highest
perceived susceptibility to disease and perceived barriers to taking action, and the lowest
self-efiicacy of any group. Individuals in the maintenance stage had the highest
perception of the benefits of eating a diet low in fit, highest self-efiicacy, lowest perceived
barriers to change and highest overall concern and motivation to comply with the opinions
of significant others. (Spomy & Contento, 1995). Curry et al., (1994) had similar results
with the individual’s perceived health status, as those with perceptions that fit intake has
an impact on health were more likely to be in the action or maintenance stages of change.
These results of the social and psychological influences on the stage of change during
dietary modification of fit intake support Prochaska’s research on the processes one goes

through While modifying problem behavior.

Chapter 4
SCHOLARLY PROJECT PROTOCOL
Nutrition Education

Steps 1 & 2: assessment. The risks associated with eating diets high in fit is a key
force in the drive to change dietary behavior. Possessing an awareness of the general
public’s level of understanding dietary fit, realizing that societal norms have a large impact
toward affecting one’s attitude toward nutritional intake, knowing the population’s
current level of dietary fat intake, and recognizing the cognitive skills one requires for
selecting food gives the primary care provider a foundation for understanding current
dietary trends in America. These findings are important to health care providers, as it
guides us in formulating an effective intervention to decreasing a person’s dietary fat
intake.

The goal of this project is to formulate a nutrition education protocol developed
from the research reviewed for the Advance Practice Nurse’s use in primary care. It will
be targeted toward the individual in the precontemplation and contemplation stages of
change. The first step involves identifying the client’s stage of readiness to change by
using an algorithm which categorizes the individual according to the limitation of fit
intake, as used in some studies mentioned above (Campbell et a1, 1994; Curry et al.,
1992; Rossi et al., 1993). As was pointed out in the literature review, the stage of change
algorithm has been identified as a valid tool for dietary fit consumption. Table 3 presents
the algorithm to be used to categorize clients into the appropriate stage of change. This

step is crucial so the APN may understand where the client is in relation to changing their

26

dietary behavior and then intervene with the most appropriate method. Table 4 represents
the method of scoring for the stage of change algorithm

The second step will be taken to assess the individual’s food behavior by using a
short dietary questionnaire which assesses fit intake by Krista], Shattuck, Henry, &
Fowler (1990). It prepares the client to start thinking about his/her own dietary behavior
and may be scored in the later stages of dietary change. In the later stages of preparation
and action, the tool may be scored and the educator and client are able to identify areas of
intervention and fornrulate an plan. Table 5 represents the dietary questionnaire that will
be used to assess dietary fit intake. Refer to Kristal, Shattuck, Henry, & Fowler (1990)
for information on scoring.

The dietary assessment and the stage of change algorithm are designed to be short,
self-administered, and ideally while in the waiting room of the primary care ofiice. It is
designed to be an assessment and intervention protocol for health promotion included as
part of the client’s yearly physical exam. These initial steps at screening are intended for
all individuals 18 and over.

Step 3: Intervention. Once the stage of readiness for dietary change has been
reviewed, focus on intervention toward the individual in the precontemplation and
contemplation stages will begin. The intervention will be nutrition education tailored to
the stage of change processes. Methods include raising the individual’s awareness of
dietary fat, enhance self-evaluation, allowing for dramatic relief and discussion of

techniques to relate the physical self with the environment.

27

Raising awareness of dietary fat is important because Transtheoretical researchers
have defined precontemplation as a stage where the individual is unaware, underaware or
does not have an interest in changing. Contemplators understand a problem exists but do
not have a plan of action. Because public knowledge about the concept of fit and what it
does in the body is relatively low, it needs to be simply explained to the client. Raising
awareness will be carried out by first presenting the risks of cardiovascular disease which
includes hypertension, obesity, diabetes, and cancer, and how they are related to ingesting
a diet that is high in dietary fit as a total percentage. A brief description of how
artherosclerosis is formed in the body and how it affects cardiovascular health and weight
will also be done. It will be a very simple explanation consisting of the following:

Dietary fit is broken down in the liver and is transported in the blood, to be
taken up by the cells. An excess amount of dietary saturated fit can lead to a high
cholesterol level in the blood, leading to plaques on the arteries. This can lead to
high blood pressure, heart disease, and stroke. Dietary fit has a higher content of
calories. One fit gram is equivalent to 9 calories, whereas 1 gram of carbohydrate
or protein is equal to 4 calories. A high daily intake of dietary fit places one at
risk for having an excessive intake of calories. An excess of caloric intake can lead
to obesity. Obesity has been associated with hypertension, cardiovascular disease,
certain cancers.

Self-evahration is also an important process identified in the precontemplation and
contemplation stages. A take-home pamphlet, the Guide to Good Eating, which explains

difi‘erent food groups, the amount of servings needed in each group and what a serving

28

constitutes, will also be reviewed together for questions / answers (United Dairy Council,
1994). Self-evaluation will be carried out by using the dietary questionnaire the client filled
out after the Guide to Good Eating is reviewed. At this time it will be asked of the client
to identify which food behaviors he or she engage in that lead to a diet that is high in fit.
If he or she is unable to, the APN will point out dietary behaviors that are high in fat and
place the individual at risk for disease. Becoming fimiliar with the Guide to Good Eating
also gives the individual a beginning foundation for the later stages of change. This sets up
the person for the “how to” in making the dietary behavior change. As was pointed out in
the literature review above, individuals are lacking the knowledge of how to pursue their
goal of decreasing their dietary fit intake.

Dramatic relief and environmental evaluation are similar processes used during
precontemplation and contemplation stages of change. Methods to ficilitate the client to
use these for dietary behavior change will be presented in two ways. The first is to ask the
client their perceptions or feeling about the possibility of making a dietary behavior change
to decrease dietary fit intake. The second approach would be to ask the individual to look
at some of the negative and positive aspects to eating a diet that is lower in dietary fit and
how it would afi‘ect his or her lifestyle. This is important because it will allow the APN to
be aware of how well the client understood the information conveyed in the awareness
raising intervention and adjust for clarification, give some insight to the client’s decision
making process, and set up the client for the preparation stage of change.

Nutrition education evaluation / research. The nutrition education protocol will be

evaluated for the ficilitation of the individual to move fiom the precontemplation and

29

contemplation stages of change to the preparation stage for the reduction of the intake of
dietary fit. As outlined above, the preparation stage of change portrays a readiness to
change in both attitude and behavior in approximately the next month. Since
precontemplation and contemplation stages were found to last anywhere fiom 6 months to
1 year, cheats will be evahrated at 6 months fiom the time of their annual physical by
sending them the stage of change algorithm with a self-addressed stamped envelope. The
algorithm will show that the client has moved on to the preparation stage of change.

At the preparation stage of change different techniques of intervention will then
need to be implemented specific for that stage, which this project does not cover.
However, for future project development, intervention can continue according to the
stages of change, focusing on the processes that occur at each stage. As was pointed out
earlier, the Food Frequency Questionnaire can be scored in the preparation and action
stages to formulate a plan and monitor the reduction of dietary fit intake. Furthermore,
this educational protocol could be set up in the same fishion as a research project for a
variety of different patient populations.

Program evaluation can be set up as was indicated above or it could be set up as a
research study to test its efiectiveness against traditional nutrition programs. Participants
can be screened based on whether they are in the precontemplation and contemplation
stages of change, are 18 years of age, and are a patient of a fimily practice group.
Participants could be randomly placed into one of three groups: an intervention group,
which receives tailored nutrition messages specific for precontemplation and

contemplation, one which receives traditional nontailored nutritional messages (as

30

previously pointed out, traditional education focuses on those that are in action and may
be inappropriate for those not ready to act), and a control group which does not receive
any nutritional messages at all At the six month point the individuals can be given the

algorithm to see if they progressed to the preparation stage of change. The APN has the

opportunity to use this nutrition education protocol in a variety of methods in nutrition

research and education.

Chapter 5
IMPLICATIONS FOR ADVANCED NURSING PRACTICE

This educational protocol, formulated to facilitate the individual to move fiom the
early stages of dietary change to the preparation stage of dietary behavior change, can be
an integral part of the primary care Advanced Practice Nurse’s approach to health
promotion. The protocol was formulated as one of the sohrtions toward the nationwide
problem of attempting to decrease American’s dietary fit intake. This document has
shown that current education methods to decrease dietary fit intake are inefi‘ective, as
only 14% of Americans are consuming a diet composed of 30% or less of fit.

It can be argued that these steps in assessment and intervention for the
precontemplation and contemplation stages are a method of disease prevention, as dietary
fat intake has been identified as a risk fictor to three of the most frequent causes of
morbidity and mortality in the United States. Since the literature shows individuals in the
precontemplation and contemplation stages of change have the highest intakes of dietary
fit, it makes this target population one of the most crucial in attempts toward disease
prevention. This document has shown the potential impact that this project could have on
the health of individuals through dietary education. The APN has the opportunity to
implement this educational protocol into family nursing practice by expanding

transtheoretical stages of change nutrition research.

31

32

Table 3
Stagm' g questions for dietag fit reduction
1. Have you ever changed your eating habits to decrease the amount of fit in your diet?
Yes 1
No 2 (Skip to #2)
1A. IF YES, Are you currently limiting the amount of fit in your diet?
Yes 1
No 2 (Skip to #2)
IB 1. IF YES, How long have you been limiting the amount of fit in your diet?
Less than 30 days 1

1-6 months 2
7-12 months 3
Over 1 year 4
1B2. IF YES, Would you say your are now eating a low-fit diet?
Yes 1
No 2

2. In the past month, have you thought about changes you could make to decrease the
amount of fit in your diet?

Yes 1

No 2
2A How confident are you that you will make some of these changes during the next

month?
Very confident 1
Somewhat confident 2
Mildly confident 3
Not at all confident 4

(Curry, Kristal, & Bowen, p. 104-105, 1992).

Table 4

Stagr_n' g Algorithm Scoring
Stage

Precontemplation

Contemplation

Preparation

Action

Maintenance

33

Question(s)

lor 1A
2

l or 1A
2
2A

1 or 1A
2
2A

1 and 1A
1B

1 and 1A
1B

(Curry, Kristal, & Bowen, p. 105, 1992).

Answer(s)

No
No

No
Yes
Mildly or not at all confident

No
Yes
Somewhat or very confident

Yes
6 months or less

Yes
7 months or more

34

Table 5

Food Frguency Minnaire

Part 1. Please circle Y
for all the foods you

YIN Breakfast cereal
YIN Oranges, grapefi'uit

YIN Margarine on breads,
vegetables, potatoes, ct

usually eat evgday or 5 (firm, not juice) YIN Butter on breads,
or more days a week. YIN Eggs YIN Lard in cooking

 

Otherwise circle N. YIN Non-fat or 1% milk

Part 2. Please circle Y

for all the foods you usually
eat at least once each week.
etc.)0therwise circle N.

YIN Low fat cottage cheese or
other low fat diet cheeses
(include snacks and
casseroles)

YIN Dark breads (whole
wheat, rye, pumpernickel)

YIN Rice, spagretti or corn

tortillas

YIN Squash (acorn, zucchini, etc)

YIN Broccoli, cauliflower, brussel
sprouts or cabbage

YIN Peas or green beans

YIN Cooked dried beans(baked,
chili, kidney, refiied, black,
etc.)

YIN Brown rice

YIN Tofu or bean curd

YIN Bananas

YIN Raisins, prunes or
other dried fi'uit

YIN Melon (cantaloupe,
watermelon, etc.)

YIN Hot dogs

YIN Hamburger

YIN Chicken with skin on

YIN Bacon

YIN Processed or lunch

meat (bologna, sausage, etc.)

YIN Green salad

YIN Salad dressings or mayonnaise
(exclude low calorie diet type)

YIN Red meat (beef, ham, pork or
pork, or lamb)

YIN A vegetable at lunch

YIN A vegetable at dinner

YIN Two or more servings of
vegetables(exclude lettuce)

YIN Two or more servings fruit

YIN Nuts or peanut butter

YIN Cookies

YIN Tuna fish

YIN Fried fish

YIN All other fish (broiled, baked,

YIN Grains, pasta or beans for main
mea1(no meet, eggs, cheese

YIN Cream or whipped cream

YIN Ice cream

YIN Sour cream

YIN Yogurt

YIN Low calorie mayonnaise or salad
dressing

YIN Food fried in restaurant
(fiench fries, chicken, etc.)

YIN Food fiied at home

YIN Pastries (donuts, danish,
sweet rolls, croissants etc.)

YIN Pies, cakes or cookies

YIN Meal in fast food restaurant

[art 3. .
A About how many times a week do you eat red meat (beef, pork, ham, lamb) for dinner or your main meal?
None Every Day
0 l 2 3 4 5 6 7
B. When you prepare or eat meat, do you trim the fat?
Trim all or most fat Trim some fat Do not trim fat

1 2 3
C. Which of the following best describes how you spread butter or margarine on bread, rolls, etc?
None Just a scrape Light coating Medium coating Thick coating
1 2 3 4 5
(Kristal, Shattuck, Henry, & Fowler, 1990)

References

Auld, G. W., Achterberg, C., Durrwachter, J., & Novak, J. (1991). Gender
differences in adults’ knowledge about fat and cholesterol. Journg of the Americar;
Dietetic Association, 91 (11), 1391-1397.

Bernstein, M. J. (1985). Consensus conference: Lowering blood cholesterol to
prevent heart disease. Journal of the American Medical Associatioa, 253 (14), 2080-
2086.

Bowen, D. J. (1992). Self-control as an intervention model for individual subjects.
In K. K DeRoos (Ed. ), Promoting Dietm Change in Communities: Appbgm’ g Existing
Models of Dietm Change to Population-Bases Interventions (pp. 11-21). Seattle, WA:
Fred Hutchinson Cancer Research Center.

Brown, M. A, & Waybrant, K M. (1988). Health promotion, education,
counseling, and coordination in primary health care nursing. Public Hea_lth Nursimgé (1),
16-23.

Campbell, M. K, DeVillis, B. M., Strecher, V. J., Ammerman, A S., DeVillis, R.
F ., & Sandler, R S. (1994). Improving dietary behavior: The efl‘ectiveness of tailored
messages in primary care settings. American Journal of Public Health. 8 (5), 783-787.

Curry, J. S., Kristal, A R, & Bowen, D. J. (1992). An application of the stage
model of behavior change to dietary fat reduction. with Edwtion Research. 7 (l), 97-

105.

35

36

Fortmann, S. P., Williams, M. S., Hulley, S. B., Haskell, W. L., & Farquhar, J. W.
(1981). Effect of health education on dietary behavior: the Stanford three community
study. American Journal of Cliaigal Nutrition, 34. 2030-2038.

Franz, M. J., & Reader, D. (1991). Diabetes and nutrition recommendations: A
practical perspective. Nurse Practitioner Forum, 2 (3), 157- 162.

Glanz, K, Patterson, R E., Krista], A. R, DiClemente, C. C., Heimendinger, J.,
Linnan, L., & McLerran, D. F. (1994). Stages of change in adopting healthy diets: Fat,

fiber, and correlates of nutrient intake. Health Education Ouarterbz, 21 (4), 499-519.

 

Greene, G. W., Rossi, S. R, Reed, G. R, Willey C., & Prochaska, J. O. (1994).
Stages of change for reducing dietary fat to 30% of energy or less. Jourgl of the
Man Dietetic Association. 94 (10), 1105-1110.

Greenwald, P., & Sondik, E. J. (Eds. ). (1986). Cilacer control objectives for the
raation: 1985-2000 (National Cancer Institute Monograph No. 2). Washington, DC:
Author.

Greidanus, I. & Contento, I. (1989). The relationship between the ability to solve
practical nutrition problems in an adult population and piagetian cognitive levels. Mal
of Nutrition Educat_ion, 21 (2), 73-81.

Harlan, W. R, & Stross, J. K (1985). An educational view of a national initiative
to lower plasma lipid levels. Journal of the Americawedfial Association. 253 (14),
2087-2090.

Institute of Medicine. Donaldson, M., Yordy, K, & Vanselow, N. (Eds. ). (1994).

Defining PM are: Ajn Interim Report. Washington, DC: National Academy Press.

37

Institute of Medicine. Thomas, P. R (Ed. ). (1991). Improving America’s Diet
and Hea_1th: From Recommendations to Action. Washington, DC: National Academy
Press.

Judd, J. T.. Clevidence, B. A, Muesing, R A, Wittes, J., Sunkin, M. E., &
Podczasy, J. J. (1994). Dietary trans fatty acids: effects on plasma lipids and lipoproteins
of healthy men and women. American Journal of Clinical Nutr'aion. 59. 861-868.

Lissner, L., Levitsky, D. A, Strupp, B. J., Kalkwarf, H J., & Roe, D. A (1987).
Dietary fat and the regulation of energy intake in human subjects. American Journal of
Mara] Nutfiaiarrna46. 886-892.

Kristal, A R, Bowen, D. J., Curry, S. J., Shattuck, A L., & Henry, H J. (1990).
Nutrition knowledge, attitudes and perceived norms as correlates of selecting low-fat
diets. H__ea_lth Educatjan Research. 5 (4), 467-477.

Kristal, A. R, Shattuck, A. L., & Henry, H J. (1990). Patterns of dietary behavior
associated with selecting diets low in fat: Reliability and validity of a behavioral approach
to dietary assessment. Journal of the MMDiatetic Associatioa, 90 (2), 214-220.

Kristal, A R, Shattuck, A L., Henry, H. J. & Fowler, A S. (1990). Rapid
assessment of dietary intake of fat, fiber, and saturated fat: Validity of an instrument
suitable for comrmmity intervention research and nutritional surveillance. American
Journal of Heflth Promotion. 4 (4), 288-295.

Lissner, L., Levitsky, D. A, Strupp, B. J., Kalkwarf, H. J., & Roe, D. A (1987).
Dietary fat and the regulation of energy intake in human subjects. American Journal of

Clinical Nutrition. 46. 886-892.

38

Marckmann, P., Sandstrom, B., & Jespersen, J. (1994). Low-fat, high-fiber diet
favorably affects several independent risk markers of ischemic heart disease: observations
on blood lipids, coagulation, and fibrinolysis from a trial of middle-aged danes. American
Journal of Cliaiaal Nutrition. 59. 93 5-939.

Medlin, G., & Skinner, J. (1990). Individual dietary intake methodology: A fifiy

year review of progress. Journal of the American Dietetic Association 88 1250-1257.

 

Melkus, G. D. (1994). Obesity: Assessment and intervention for primary care
practice. Nurse Practitioner Forum. 5 (1), 28-33.

Mion, L. C., McDowell, J. A, & Heaney, L. K (1994). Nutritional assessment of
the elderly in the ambulatory care setting. Nurse Practitioner Forum. 5 (1), 46-51.

Murphy, S. R, Rose, D., Hudes, M., & Viter, F. E. (1991). Demographic and
economic factors associated with dietary quality for adults in the 1987-1988 nationwide

food consumption survey. Journal of the American Dietetics Association 92 1352-1357.

 

 

National Cancer Institute. (1984). Cancer prevention research W"

nutrition (National Institutes of Health Publication No. 84-2616). Washington, DC: U.

 

S. Government Printing Oflice.

National Institutes of Health. (1985). Health implications of obesity: National
institutes of health consensus development conference statement. Annfi of Interaal
Medicine. 103. 1073-1077.

O’Connell, D., & Velicer, W. F ., (1988). A decisional balance measure and the
stages of change model for weight loss. The International Journal of the Addictions,2_3

(7), 729-750.

39

Prochaska, J. O. (1989). What causes people to change from unhealthy to health
enhancing behavior? In C. C. Cummings & J. D. Floyd (Eds), Humanitiehavior and cancer
[iakkreductionr Overview and report of a conference on unmet research needs (pp. 30-34).
Atlanta, GA: American Cancer Society.

Prochaska, J. O. (1992). A transtheoretical model of behavior change:
Implications for diet interventions. In K K DeRoos (Ed. ), Promoting Dietgy Change in
Communities: Appbg’ g Existiag Models of Dietm Change to Population-Bases
Interventions (pp. 11-21). Seattle, WA: Fred Hutchinson Cancer Research Center.

Prochaska, J. 0., & DiClemente, C. C. (1992). Stages of change in the
modification of problem behaviors. In M. Henderson, R M. Eisler, & P. M. Miller (Eds),
Progaess in Behavior Modification (pp. 184-214). Sycamore, IL: Sycamore Press.

Prochaska, J. 0., DiClemente, C. C., & Norcross, J. C. (1992). In search of how
people change: Applications to addictive behaviors. American chhologg' , 47 (9), 1102-
1114.

Prochaska,].(1,1Ieficer,VV.Ii,lhos§,].Si,(30khuentghd.(i,thucmmin.lI,
Rakowski, W., Fiore, C., Harlow, L. L., Redding, C. A, Rosenbloom, D., & Rossi, S. R
(1994). Stages of change and'decisonal balance for 12 problem behaviors. Haaatli
chhology, 13 (1), 39-46.

Ramsey, J. A, McKinzie, J. K, & Fish, D. G. (1982). Physicians and Nurse
Practitioners: Do they provide equivalent health care?. Jauanal of Public Hea_ltaJ2 (1),

55-57.

 

40

Riflrind, B. (1984). The lipid research clinics coronary primary prevention trial
results. Journal of the American Medical Assoicatioa, 251 (3), 351-364.
Rosenblatt, E. (1989). Weight loss counseling in primary care. Journal of the

American Academy of Nurse Practitioners l (4), 112-118.

 

Rossi, S. R, Greene, G. W., Reed, G., Prochaska, J. O., Velicer, W. F., & Rossi,
J. S. (1993, March). A comparison of four stage of change algorithms for dietg fat
reduction. Paper presented at the Society for Behavioral Medicine Annual Meeting, San
Francisco, CA

Russel, N. K, & Roter, D. L. (1993). Health promotion counseling of chronic-
disease patients during primary care visits. Amadcan Joumal of Pablic Heflfla 83 (7), 979-
982.

Saunders, R P., & Rahilly, S. A, (1990). Influences on Intention to reduce dietary
intake of fat and sugar. Journal of Nutria'on Educatioa, 22 (4), 169-176.

Schreiner, B., & Brondum, L. A (1994). Nutrition in pediatric primary care:
Assessment and common problems. Nurse Practitioner Pom, 5 (1), 13-23.

Schucker, B., Bailey, K, Heimbach, J. T., Mattson, M. E., Wittes, J. T., Haines,
C. M., Gordon, D. J., Cutler, J. A, Keating, V. S., Goor, R S., & Rifltind, B. M. (1987).
Changes in public perspective on cholesterol and heart disease: Results fi'om two national

surveys. Journal of the American Medical Association 258 (24), 3527-3531.

 

Spomy L. A, & Contrreto, I. R (1995). Stages of change in dietary fat reduction:

Social psychological correlates. Journal of Nutrition Educaaion. 27 (4), 191- 199.

41

United Dairy Council (1994). Q_ui_de to Good Em Rosemont, 111: United
Dairy Council

U. S. Department of Health and Human Services. (1994). Healthy people 2000:
Iguana] health promotion and disease prevention objectives (DHHS Publication No. 95-
1256-1). Washington, DC: Author.

U. S. Department of Health and Human Services. (1988). The surgeon general’s
Leport on nutrition and hem (DHHS Publication No. 88-50210). Washington, DC:
Author.

Wechsler, H, Levine, S., Idelson, R K, Rohman, M., & Taylor, J. O. (1983). The
physician’s role in health promotion - A survey of primary care practitioners. The New

I_ipgland Journal of Medicine. 308 (2), 97-100.

 

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