Association of sociodemographic factors with barriers reported by patients receiving nutrition counseling as part of cardiac rehabilitation

Sex Differences in Cardiac Rehabilitation Outcomes

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Barriers and facilitators to participant adherence of dietary recommendations within comprehensive cardiac rehabilitation programmes: a systematic review

OBJECTIVE

To identify individual-, provider- and system/environmental-level barriers and facilitators affecting cardiac rehabilitation (CR) participants' adherence to dietary recommendations.

DESIGN

A systematic review of the medical literature was conducted. Six databases were searched from inception through March 2021: APA PsycInfo, CINAHL, Embase, Emcare, Medline and PubMed. Only those studies referring to barriers and facilitators reported by CR participants were considered. Pilot and case report studies, non-peer-reviewed literature and studies published in a language other than English, Portuguese or Spanish were excluded.

RESULTS

Data were extracted and analysed on the basis of individual-, provider- and system/environmental-level factors. Of 2083 initial citations, sixteen studies were included, with nine being qualitative and seven observational in design. From these, ten multi-level barriers and seven multi-level facilitators were identified. Dietary recommendations included developing healthy eating habits, transitioning to vegetarian-rich diets and increasing fish oil and n-3 intake. Only one study reported on all of the nutrition education programme factors recommended by the Workgroup for Intervention Development and Evaluation Research.

CONCLUSION

To the best of our knowledge, this review is the first to summarise specific barriers and facilitators to recommendation adherence among CR participants. Few of the studies offered any conclusions regarding programme design that could facilitate improved dietary adherence practices. Future studies should aim to explore patient perspectives on the nutritional patterns and recommendations outlined in the Mediterranean Diet, the Dietary Approaches to Stop Hypertension Diet, Vegetarian or Vegan diets and the Portfolio Diet.

Motivators, barriers and strategies of weight management: A cross-sectional study among Finnish adults

BACKGROUND

Weight management (WM) is an ongoing global challenge. The purpose of this study was to analyze motivators, barriers, and strategies of WM among Finnish adults.

METHODS

Data were collected in the 'KULUMA' (Consumers at the Weight Management Market) project among 667 community-dwelling adults in Eastern and Central Finland (Kuopio and Jyväskylä). The self-reported questionnaire collected background information and responses to motivators, barriers, and strategy items. Principal component analysis (PCA) was used to extract components of motivators, barriers, and strategies of WM, along with K-means clustering to categorize the participants.

RESULTS

About 55% of the respondents were aiming to lose weight. The PCA resulted in a 3-component model for motivators (functional aspects, sociological aspects, and psychosocial aspects), a 4-component model for barriers (life situations, food environment, personal issues, and resources) and a 2-component model for the strategies of WM (dietary strategies and life-management strategies). The components had several relationships with demographic characteristics (especially with age) but only a few with weight-related characteristics (e.g. weight loss attempts). Three clusters of participants were formed: Struggling weight managers (WMs), Independent WMs, and Determined WMs. Barriers to WM had a key role in differentiating clusters and weight satisfaction. Determined WMs were the most satisfied with their weight, whereas Struggling WMs perceived the highest level of barriers to WM.

CONCLUSIONS

WM efforts are common among Finnish adults. Generally, weight-related activities and communication in society should focus more on barriers than merely on the motivation or strategies of WM in order to support individuals' WM efforts.

Perceived Barriers to Weight loss Programs for Overweight or Obese Women

BACKGROUND

In order to develop appropriate obesity control and treatment strategies, the key point is to understand the barriers perceived by overweight or obese people in trying to follow weight-loss programs. This study examined perceived barriers to weight-loss programs among overweight or obese women.

METHODS

In this descriptive-analytical study, 204 overweight or obese women aged 31.97± 10.62 yr, were selected randomly from the nutritional counseling centers in 2008 in Tabriz, Iran. The mean BMI was 33.83 ±5.75 kg/ m2. A structured questionnaire including questions on barriers to weight-loss diet and physical activity was filled out for each participant by face-to-face interview. Height and weight measured objectively and demographic details were obtained. Data analysis carried out using multiple regression and factor analysis.

RESULTS

The most important perceived barriers to weight-loss diets were 'situational barriers', stress, depression, and food craving. High educational level was independent determinant of situational barriers (β=0.329, P=0.048). Employee women had a higher mean score on stress and depression than students and housewives. Lack of time and exercising lonely were the most important items of "External barriers" and Lack of motivation was the most important item of "internal barriers" to physical activity. Employment and being student were highly associated with external barriers (β=1.018, P<0.001 and β=0.541, P= 0.002). Moreover, older women who had low educational level, perceived more internal barriers.

CONCLUSION

Weight reducing strategies should take into account the specific perceived barriers to weight-loss diets faced by overweight or obese women, particularly situational barriers, stress and depression and food craving; and lack of time and lack of motivation as barriers to physical activity.

Understanding dietary decision-making in patients attending a secondary prevention clinic following myocardial infarction

AIMS AND OBJECTIVES

This study aimed to explore the issues that influence the dietary choices made by patients attending a secondary prevention clinic following a myocardial infarction.

BACKGROUND

Secondary prevention clinics play an important role in promoting dietary advice, yet evidence suggests that many individuals are neither implementing nor maintaining the lifestyle changes recommended. Research largely focuses on compliance to lifestyle changes in general, and only a small number of quantitative studies address the issues surrounding adherence to dietary advice.

DESIGN

Phenomenology was selected as the most appropriate approach for this qualitative study, enabling patients' lived experiences of dietary decision-making to be explored.

METHOD

A purposive sample of nine participants was selected from a cardiac secondary prevention clinic. Semi-structured interviews were taped, transcribed and analysed using an interpretative approach.

RESULTS

Data analysis produced six central themes contributing to patients' decision-making. Fear, determination and self-control were enabling factors and poor recall of information, a need for additional support and a lack of will power were disabling factors. Findings suggest that patient motivation and ability to make sustainable dietary change can decline as disabling factors reduce determination and self-control, and initial fear of their heart condition subsides.

CONCLUSION

In this study, patients' motivation regarding dietary decision-making changed over time and was strongly influenced by a fear of future heart problems.

RELEVANCE TO CLINICAL PRACTICE

Health care professionals need to understand the temporal nature of decision-making postmyocardial infarction and adopt a wide repertoire of responsive strategies that support patients to follow a healthy diet in the longer term.

A Study of Dietary Patterns in the Mexican-American Population and Their Association with Obesity

OBJECTIVE

Data from the National Health and Nutrition Examination Survey 2001-2002 indicate that prevalence of overweight and obesity continues to rise among Mexican Americans. Little is know about the dietary factors associated with this trend. Ethnic groups have different dietary patterns based on their geographical locations and cultural influences. We examined the dietary patterns of Mexican Americans and their association with total and central obesity. We hypothesized that Mexican-American adults following a traditional diet would have a lower prevalence of obesity than those following a more typical American diet.

SUBJECTS

Data from the National Health and Nutrition Examination Survey 2001-2002 included 659 Mexican-American adults, ages 18 years and older.

EXPERIMENTAL DESIGN

Dietary patterns were defined by cluster analysis of food group variables, expressed as percentage contribution to total energy intake. Obesity was assessed by body mass index (calculated as kg/m2) and central obesity by waist circumference.

RESULTS

We defined four dietary patterns, each named for the food groups that were most predominant relative to the other clusters: poultry and alcohol, milk and baked products, traditional Mexican, and meat. Surprisingly, we did not identify a clear "healthy pattern" group in this population, as has been generally observed in other ethnic groups. Although the traditional Mexican diet contains relatively high intakes of legumes and dietary fiber, it also was high in cholesterol. Contrary to our hypothesis, those consuming the traditional Mexican diet pattern had high BMI and waist circumference values, which did not differ significantly from other groups.

CONCLUSION

In this representative population of Mexican-American adults, we identified distinct dietary patterns, but these were not significantly associated with obesity. Rather, obesity was prevalent in all diet groups. More details on possible changes within the traditional pattern, including use of fast food vs home-prepared Mexican foods, are needed to better understand how diet can be associated with obesity in this population.

Position of the American Dietetic Association: Total Diet Approach to Communicating Food and Nutrition Information

It is the position of the American Dietetic Association that the total diet or overall pattern of food eaten is the most important focus of a healthful eating style. All foods can fit within this pattern, if consumed in moderation with appropriate portion size and combined with regular physical activity. The American Dietetic Association strives to communicate healthful eating messages to the public that emphasize a balance of foods, rather than any one food or meal. Public policies that support the total diet approach include the Dietary Guidelines for Americans, MyPyramid, the DASH Diet (Dietary Approaches to Stop Hypertension), Dietary Reference Intakes, and nutrition labeling. The value of a food should be determined within the context of the total diet because classifying foods as "good" or "bad" may foster unhealthful eating behaviors. Alternative approaches may be necessary in some health conditions. Eating practices are dynamic and influenced by many factors, including taste and food preferences, weight concerns, physiology, lifestyle, time challenges, economics, environment, attitudes and beliefs, social/cultural influences, media, food technology, and food product safety. To increase the effectiveness of nutrition education in promoting sensible food choices, food and nutrition professionals should utilize appropriate behavioral theory and evidence-based strategies. A focus on moderation and proportionality in the context of a healthful lifestyle, rather than specific nutrients or foods, can help reduce consumer confusion. Proactive, empowering, and practical messages that emphasize the total diet approach promote positive lifestyle changes.

Participants' willingness to consume soy foods for lowering cholesterol and receive counselling on cardiovascular disease by nutrition professionals

Objectives

To determine if participants would be interested in consuming soy foods to lower cholesterol in primary and secondary prevention of heart disease, and to identify the role physicians and registered dietitians have in providing dietary advice, about soy foods or other foods, for participants with elevated cholesterol.

Methodology

Qualitative data from 12 focus groups were gathered from a convenience sample of 74 adults, aged 18–91 years, with and without high cholesterol (total cholesterol >200 mg dl−1). Participants were recruited from Minneapolis/St. Paul mainstream and natural foods grocery stores. Focus group interviews were taped and transcribed verbatim. Common themes were identified, coded and compared using NVivo computer software.

Results

Participants believed diet, lifestyle and genetics were the cause of high cholesterol and cardiovascular disease (CVD). Few participants were aware of the Food and Drug Administration health claim for soy protein, yet many were willing to consume soy as part of lifestyle modification to prevent CVD. They reported preferring food and exercise over medication to treat high cholesterol. Few participants had ever received dietary advice from physicians on treating high cholesterol or CVD, and most doubted the accuracy of such advice. They believed registered dietitians were the most credible source of nutrition counselling and expressed an interest in physician referrals to dietitians.

Conclusions

A collaboration and referral system between physicians and registered dietitians could increase CVD patients' consumption of soy foods as a means potentially leading to a reduced risk of heart disease in participants.

Nutrition guidance in Dutch family practice: behavioral determinants of reduction of fat consumption

BACKGROUND

Studies have shown that the psychosocial determinants attitude, self-efficacy, subjective norm, and health threat are important in predicting intention to change fat consumption. However, the role of habit in relation to these determinants is still largely unknown.

OBJECTIVE

We aimed to assess whether and how habit influences intention in relation to attitude, self-efficacy, subjective norm, and health threat.

DESIGN

Cross-sectionally, we studied the self-reported psychosocial determinants and intention of 105 (52 intervention, 53 control) patients who participated in a family practice-based tailored nutrition counseling intervention study for lowering cardiovascular risk. Fat intake 15 mo before the assessment of psychosocial determinants was used as a measure of habit. We used logistic regression analyses to develop a model predicting intention to change fat consumption.

RESULTS

Our regression model explained 43% of the variance in intention. Patients who perceived higher subjective norm or more social support had a higher intention. Habit was a significant predictor of intention in interaction with self-efficacy and health threat. Attitude, health threat, age, and group membership (ie, whether patients had been in the intervention group or the control group of the intervention study) were also included in the regression model.

CONCLUSIONS

The results suggest that habit in addition to subjective norm and the other more frequently investigated psychosocial determinants are important in predicting intention to change fat consumption. To achieve sustainable health improvement through nutrition education programs, these programs should therefore start focusing more on subjective norm and habit.

Behavior change outcomes in an outpatient cardiac rehabilitation program

OBJECTIVE

To evaluate the effectiveness of nutrition education within an outpatient cardiac rehabilitation program.

DESIGN

Subjects were assigned, according to participation in cardiac rehabilitation programs in two community hospitals within an integrated healthcare system, to either a treatment (n=54), or a control group (n=50).

SUBJECTS/SETTING

One hundred four men and women, age range 35 to 85 years, participating in a 6-week cardiac rehabilitation program. Most were men (80%) and overweight. The majority presented with the diagnosis of myocardial infarction followed by coronary artery bypass surgery or percutaneous transluminal coronary angiography procedure.

INTERVENTION

Subjects in the control group received usual nonindividualized nutrition education from cardiac rehabilitation therapists. Subjects in the treatment group attended two group nutrition education classes and one individual diet counseling session, all led by the same dietitian.

MAIN OUTCOME MEASURES

Changes in fat, saturated fat, cholesterol, and carbohydrate intake, and restaurant eating habits as assessed by the Diet Habit Survey; changes in cardiac diet self-efficacy; and changes in health-related quality of life. Statistical analyses performed Group-by-time analysis of variance with repeated measures, chi2 test.

RESULTS

The treatment group had greater improvement in Restaurant and Recipes scores on the Diet Habit Survey (2.6 vs 1.0) and a greater cardiac diet self-efficacy mean score (4.3) compared with the control group (3.8), with the greatest change in items related to eating in restaurants, away from home, or when alone. From entry into the program to discharge, the cholesterol-saturated fat index decreased significantly in the control group (from 57 to 48), and in the treatment group (from 51 to 42). The percent of energy from carbohydrate increased significantly in the control group (from 51% to 55%) and in the treatment group (from 53% to 57%). There were no differences between groups over the 3 time periods (baseline, 6 weeks, and 3-month follow-up) (n=39 for control group and n=47 for treatment group for all 3 time periods).

APPLICATIONS/CONCLUSIONS

Nutrition education within an outpatient cardiac rehabilitation program can improve dietary choices at restaurants and boost self confidence in the ability to adhere to a lipid-lowering diet.

Position of the American Dietetic Association: total diet approach to communicating food and nutrition information

It is the position of the American Dietetic Association that all foods can fit into a healthful eating style. The ADA strives to communicate healthful eating messages to the public that emphasize the total diet, or overall pattern of food eaten, rather than any one food or meal. If consumed in moderation with appropriate portion size and combined with regular physical activity, all foods can fit into a healthful diet. Public policies that support the total diet approach include Reference Dietary Intakes, Food Guide Pyramid, Dietary Guidelines for Americans, Nutrition Labeling and Healthy People 2010. The value of a food should be determined within the context of the total diet because classifying foods as "good" or "bad" may foster unhealthy eating behaviors. Eating practices are influenced by taste and food preferences, concerns about nutrition and weight control, physiology, lifestyle, environment, and food product safety. To increase the effectiveness of nutrition education in promoting sensible food choices, dietetics professionals plan communications and educational programs that utilize theories and models related to human behavior. Communication campaigns/programs should implement an active, behaviorally focused approach within the larger context of food choices. Nutrition confusion can be reduced by emphasizing moderation, appropriate portion size, balance and adequacy of the total diet over time, the importance of obtaining nutrients from foods, and physical activity.

Nutrition and cognitive impairment in the elderly

As the number of older people is growing rapidly worldwide and the fact that elderly people are also apparently living longer, dementia, the most common cause of cognitive impairment is getting to be a greater public health problem. Nutrition plays a role in the ageing process, but there is still a lack of knowledge about nutrition-related risk factors in cognitive impairment. Research in this area has been intensive during the last decade, and results indicate that subclinical deficiency in essential nutrients (antioxidants such as vitamins C, E and beta-carotene, vitamin B(12), vitamin B(6), folate) and nutrition-related disorders, as hypercholesterolaemia, hypertriacylglycerolaemia, hypertension, and diabetes could be some of the nutrition-related risk factors, which can be present for a long time before cognitive impairment becomes evident. Large-scale clinical trials in high-risk populations are needed to determine whether lowering blood homocysteine levels reduces the risk of cognitive impairment and may delay the clinical onset of dementia and perhaps of Alzheimer's disease. A curative treatment of cognitive impairment, especially Alzheimer's disease, is currently impossible. Actual drug therapy, if started early enough, may slow down the progression of the disease. Longitudinal studies are required in order to establish the possible link of nutrient intake--nutritional status with cognitive impairment, and if it is possible, in fact, to inhibit or delay the onset of dementia.

Reported adoption of dietary fat and fiber recommendations among consumers

OBJECTIVE

To identify constraints in adopting dietary fat and fiber recommendations.

DESIGN

A questionnaire was mailed to a sample of the general population, a convenience sample of persons with heart disease and cancer in 11 states, and registered dietitians in 5 states. The survey included questions on demographic and attitudinal factors that were correlated with specific practices to reduce fat intake and increase fiber intake.

SETTING

From the general population sample of 6,206 eligible respondents (return rate of 51.5%), those selected were respondents who indicated that they would adopt a dietary recommendation if it were good for them (n = 2,682). Subsamples from the general population were matched to 362 registered dietitians and 147 persons with cancer or heart disease on selected demographic variables. Factors associated with adoption of specific behaviors were identified.

STATISTICAL ANALYSIS PERFORMED

Statistical analysis included chi 2, factor analysis, and analysis of variance.

RESULTS

The majority of persons who said they would adopt a fat-reducing behavior if it were good for their health reported practicing that behavior often or usually. More than 60% reported consuming whole grains; however, only 15% reported eating fruits and vegetables frequently. Among the general population sample, those more likely to practice a behavior had the following characteristics: female, college educated, older than 60 years, white, higher income, no children younger than 18 years, perceived health status as excellent, and absence of chronic disease. Registered dietitians and those with chronic disease were also more likely to follow dietary fat and fiber recommendations.

APPLICATIONS

Nutrition education messages that lead to increased consumption of dietary fiber need to be developed. Nutrition educators should provide strategies for consumers for increasing use of fruits and vegetables in all meals. Good taste and convenience are critical components. The food industry may assist by providing a wider array of convenience entrees or side dishes that feature produce and whole grains.