Determinants of lifestyle behavior change to prevent type 2 diabetes in high-risk individuals.

BACKGROUND: Although there are many effective lifestyle interventions for type 2 diabetes (T2DM) prevention, insight into effective intervention pathways, especially of long-term interventions, is often lacking. This study aims to provide insight into the effective intervention pathways of the SLIMMER diabetes prevention intervention using mediation analyses. METHODS: In total, 240 participants at increased risk of T2DM were included in the analyses over 18 months. The intervention was a combined lifestyle intervention with a dietary and a physical activity (PA) component. The primary and secondary outcomes were change in fasting insulin (pmol/L) and change in body weight (kg) after 18 months, respectively. Firstly, in a multiple mediator model, we investigated whether significant changes in these outcomes were mediated by changes in dietary and PA behavior. Secondly, in multiple single mediator models, we investigated whether changes in dietary and PA behavior were mediated by changes in behavioral determinants and the participants' psychological profile. The mediation analyses used linear regression models, where significance of indirect effects was calculated with bootstrapping. RESULTS: The effect of the intervention on decreased fasting insulin was 40% mediated by change in dietary and PA behavior, where dietary behavior was an independent mediator of the association (34%). The effect of the intervention on decreased body weight was 20% mediated by change in dietary and PA behavior, where PA behavior was an independent mediator (17%). The intervention significantly changed intake of fruit, fat from bread spread, and fiber from bread. Change in fruit intake was mediated by change in action control (combination of consciousness, self-control, and effort), motivation, self-efficacy, intention, and skills. Change in fat intake was mediated by change in action control and psychological profile. No mediators could be identified for change in fiber intake. The change in PA behavior was mediated by change in action control, motivation, and psychological profile. CONCLUSION: The effect of the SLIMMER intervention on fasting insulin and body weight was mediated by changes in dietary and PA behavior, in distinct ways. These results indicate that changing dietary as well as PA behavior is important in T2DM prevention.

Nutrition awareness before and throughout different trimesters in pregnancy: a quantitative study among Dutch women.

OBJECTIVE: To examine the nutrition awareness of women before and during pregnancy in order to provide a greater understanding of the life course perspective (LCP) in relation to nutrition behaviours and pregnancy. METHOD: Data were collected in a cross-sectional study with the aid of a face-to-face interview, based on our conceptualization of nutrition awareness and the 'rules of thumb' designed by the Dutch Nutrition Centre. The sample consisted of five groups each of ~100 Dutch nulliparous women: women not trying to conceive a child, women trying to conceive a child and women in their first, second or third trimesters of pregnancy. RESULTS: The measurement tool based on our conceptualization of nutrition awareness resulted in a Cronbach's alpha of 0.84. Pregnant women are significantly more aware of their nutrition than women who are not trying to conceive. The scores on nutrition awareness do not differ significantly between the three trimester groups of pregnant women. Women who are trying to conceive do not have a significantly higher nutrition awareness than women who are not trying to conceive. CONCLUSIONS: Our conceptualization of nutrition awareness has shown to be fruitful in obtaining a better understanding of behavioural changes in health. The study provided indications in favour of the LCP; pregnancy could indeed be an event in a woman's life that causes increased nutrition awareness. This should be kept in mind when healthy nutrition promotion activities are being developed.

Changes in markers of cobalamin status after cessation of oral B-vitamin supplements in elderly people with mild cobalamin deficiency.

Mildly cobalamin-deficient elderly were supplemented with 1000 microg cobalamin (group C, n=34), 1000 microg cobalamin with 400 microg folic acid (group CF, n=31) or a placebo (n=30) for 6 months. Participants provided one single blood sample 3, 5 or 7 months after cessation of supplementation to monitor early changes in plasma concentrations of cobalamin, holotranscobalamin (holoTC) and methylmalonic acid (MMA). At the end of supplementation (groups C+CF), one participant met our criteria for mild cobalamin deficiency, as did 13, 14 and 43% of the participants assessed at respectively 3, 5 and 7 months post-supplementation. Cobalamin and holoTC declined on average with 47 and 56% relative to concentrations at the end of supplementation for the group assessed at 7 months post-supplementation. Essentially similar declines were observed for those participants assessed at 3 and 5 months post-supplementation. Mean MMA concentrations increased by 15% (P=0.07) in those participants assessed at 3 and 5 months post-supplementation, and increased by 50% (P=0.002) in those participants assessed at 7 months post-supplementation. Considering MMA as a sensitive tissue marker for cobalamin status, oral supplementation may afford adequate cobalamin status for a period of up to 5 months after cessation in the majority of participants.

A comparison of Dutch family doctors' and patients' perspectives on nutrition communication.

BACKGROUND: In recent years, we have investigated both patients' and family doctors' communicative characteristics towards nutrition communication in general practice with several qualitative and quantitative studies. A sound comparison of the survey results between both conversation partners has not been made before. OBJECTIVE: The aim of the present study was to put together data obtained by earlier studies for the first time in order to make comparisons of patients' and family doctors' communicative characteristics regarding nutrition communication. METHODS: In The Netherlands, 603 patients completed a face-to-face interview-assisted questionnaire (65% response rate) and 267 family doctors completed a questionnaire (45% response rate). RESULTS: When comparing communicative characteristics, patients stronger believed that nutrition was an influence on health than family doctors. They also attributed a greater role to personal hygiene, stress and heredity, while family doctors were more convinced of the role of alcohol use and smoking on health. Patients more often rated their own nutrition knowledge as good than family doctors. In contrast, family doctors showed higher interest in nutrition and nutrition information than patients. As a result, a collinear model for family doctors and nutrition communication towards patients was provided. CONCLUSIONS: Significant differences between patients and family doctors were found for several communicative characteristics towards nutrition communication. It is important that family doctors become convinced that patients perceive them as a reliable and expert source of nutrition information. It is recommended that family doctors raise nutrition awareness among patients. Finally, we advise family doctors to pay attention to nutrition communication styles.

The development of a minimal intervention strategy to address overweight and obesity in adult primary care patients in The Netherlands.

BACKGROUND: Currently, overweight and obesity do not receive the attention they deserve from the Dutch GPs, mostly because of a lack of an effective intervention strategy to tackle this difficult health problem. OBJECTIVE: To develop a minimal intervention strategy (MIS) addressing overweight and obesity among adult primary care patients, resulting in a prototype. METHODS: Following the intervention mapping protocol, the MIS is based on literature study, existing interventions, psychosocial theories, stakeholder interviews and a questionnaire study among stakeholders. This led to the development of a prototype of the MIS materials: a screening flow chart and a treatment flow chart, a manual and patient education materials. A pre-test among 42 general practitioners and practice nurses was conducted to investigate the usefulness of the MIS materials at first sight. RESULTS: The stakeholder interviews and the questionnaire study resulted in insight on what the MIS should look like. For instance, the stakeholders indicated that the treatment needs to focus on helping patients to eat more healthy and exercise more, using techniques like motivational interviewing. The pre-test showed that most participants were enthusiastic about the materials, although they made some suggestions on improvements. CONCLUSION: The MIS materials seem to be useful and promising. A future pilot test is needed to investigate its usefulness in daily practice and to further improve the materials in preparation for a process and effect evaluation.

Effect and maintenance of the SLIMMER diabetes prevention lifestyle intervention in Dutch primary healthcare: a randomised controlled trial.

BACKGROUND/OBJECTIVES: To assess the effectiveness of the SLIMMER combined dietary and physical activity lifestyle intervention on clinical and metabolic risk factors, dietary intake, physical activity, and quality of life after 12 months, and to investigate whether effects sustained six months after the active intervention period ended. SUBJECTS/METHODS: SLIMMER was a randomised controlled intervention, implemented in Dutch primary healthcare. In total, 316 subjects aged 40-70 years with increased risk of type 2 diabetes were randomly allocated to the intervention group (10-month dietary and physical activity programme) or the control group (usual healthcare). All subjects underwent an oral glucose tolerance test and physical examination, and filled in questionnaires. Identical examinations were performed at baseline and after 12 and 18 months. Primary outcome was fasting insulin. RESULTS: The intervention group showed significantly greater improvements in anthropometry and glucose metabolism. After 12 and 18 months, differences between intervention and control group were -2.7 kg (95% confidence interval (CI): -3.7; -1.7) and -2.5 kg (95% CI: -3.6; -1.4) for weight, and -12.1 pmol l-1 (95% CI: -19.6; -4.6) and -8.0 pmol l-1 (95% CI: -14.7; -0.53) for fasting insulin. Furthermore, dietary intake, physical activity, and quality of life improved significantly more in the intervention group than in the control group. CONCLUSIONS: The Dutch SLIMMER lifestyle intervention is effective in the short and long term in improving clinical and metabolic risk factors, dietary intake, physical activity, and quality of life in subjects at high risk of diabetes.

Nutrition communication styles of family doctors: results of quantitative research.

OBJECTIVE: To assess the nutrition communication styles of Dutch family doctors and in particular to assess its psychosocial and sociodemographic correlates. DESIGN: A cross-sectional study in which a representative sample of 600 Dutch family doctors completed a questionnaire. SETTING: The survey was conducted in October and November 2004 in the Netherlands. SUBJECTS: A total of 267 family doctors completed the questionnaire (response rate 45%). METHODS: Principal component factor analyses with varimax rotation were performed to construct factors. Cronbach's alpha was used as an index of reliability. Our hypothetical model for nutrition communication style was tested using multiple regression analysis, combining the forward and backward procedures under the condition of the same results. RESULTS: Many family doctors felt at ease with a motivational nutrition communication style. The main predictor for motivational nutrition communication style was task perception of prevention (26%). Some individual and environmental correlates had an additional influence (explained variance 49%). Other styles showed explained variances up to 57%. The motivational style was the best predictor for actual nutrition communication behaviour (35%), while the confrontational style was the best predictor for actual nutrition communication behaviour towards overweight (34%). CONCLUSIONS: In contemporary busy practice, family doctors seem to rely on their predominant nutrition communication style to deal with standard situations efficiently: for the majority, this proved to be the motivational nutrition communication style. Moreover, family doctors used a combination of styles. This study suggests that family doctors behave like chameleons, by adapting their style to the specific circumstances, like context, time and patient. If family doctors communicate about nutrition in general, they select any of the five nutrition communication styles. If they communicate about overweight, they pick either the confrontational or motivational style.

Nutrition-related information-seeking behaviours before and throughout the course of pregnancy: consequences for nutrition communication.

BACKGROUND: Research has shown that especially pregnant women, and also women with a wish for a child, have increased nutrition awareness. Seeking nutrition information seemed to be an important determinant for nutrition awareness. However, little research has been carried out about nutrition-related information-seeking behaviours before and during pregnancy. OBJECTIVE: This study aimed to explore nutrition-related information sources, nutrition information-seeking behaviours and motives for seeking nutrition information before and throughout the course of pregnancy. DESIGN: Data were collected by means of retrospective in-depth face-to-face interviews of 1 h with five groups of 12 women: women with a child wish, women in their first, second and third trimester of the first pregnancy and women in their first trimester of the second pregnancy. Women were mainly selected via midwifery practices. The interviews took place at conference rooms or at the respondent's home. Qualitative data were analysed with the software program NUD(*)IST (QSR, Melbourne). This was based on the research objectives and relevant text segments of transcripts. RESULTS: Women with a child wish generally sought little nutrition information because they were not pregnant yet. Information sources were the Internet (anonymous) and the social environment (models). In relation to the manifestation of nutrition-related information-seeking behaviours during first-time pregnancies, three groups of women could be distinguished: (1) women who feel like a mother from the moment they know that they are pregnant, (2) women who feel like a mother later in pregnancy and (3) women who do not feel like a mother yet. Each group had its own specific information-seeking behaviour. Important information sources of the first group were the Internet (anonymous and up to date), books (extended) and midwives (expert) during the first trimester; the 9-month calendar (fun and tips), friends (experienced) in the second trimester; and friends (information on breastfeeding) in the third trimester. Information sources of the second group of women were mainly brochures provided by the midwife and the midwife herself. The third group of women mainly relied on their own common sense. Second-time pregnant women mainly relied on their experience, the midwife and books for specific questions. CONCLUSIONS: Pregnant women perceive pregnancy-specific nutrition information as important because it is one of the few things that they can apply in their daily lives to protect the health of the fetus. Nutrition-related information-seeking behaviours mainly were pregnancy specific in character, rather than directed to general nutrition information.

Personalized nutrition communication through ICT application: how to overcome the gap between potential effectiveness and reality.

The potential effectiveness of personalized nutrition communication through the Internet is promising in terms of addressing personal relevance, flexibility, interactive options and amount of people that can be reached. However, little research on the contribution to behaviour change has been done. The MyFood program at Wageningen University aims at providing insight into strategies to implement personalized nutrition communication through interactive tools. In this article we present the framework for research on social acceptance of personalized nutrition communication through interactive computer technology as part of the MyFood program.

Quality of weight-loss counseling by Dutch practice nurses in primary care: an observational study.

BACKGROUND/OBJECTIVE: To assess the quality of weight-loss counseling provided by Dutch primary care practice nurses (PNs) to overweight and obese patients including both PNs' compliance with the Five A's Model for behavioral counseling in primary care, and the use of different communication styles. In addition, relationships between PN/patient characteristics (including Five A's) and communication styles will be examined. SUBJECTS/METHODS: In this observational study, 100 videotaped real-life consultations, collected in 2010/2011, were viewed using an observational checklist. Selection of consultations was based on PNs' registration of patient's complaint. The quality of weight-loss counseling was assessed by the Five A's Model (sequence of evidence-based practice behaviors that are effective for helping patients to change health behaviors) and by PNs' communication styles. Moreover, several PN and patient characteristics were registered. Descriptive statistics and logistic regression analysis were conducted with significance set at P<0.05. RESULTS: PNs most frequently arranged follow-up, assessed the risk and current behavior and advised. However, they rarely assisted in addressing barriers and securing support. For weight or physical activity, most PNs used a motivational communication style. In discussions of nutrition, they mostly used an informational communication style. Moreover, PNs used a combination of communication styles. PN characteristics, including their behavior concerning the Five A's, were stronger related to communication styles than patient characteristics. CONCLUSIONS: PNs reasonably complied with the Five A's Model. The quality of PNs' weight-loss counseling might be increased by routinely providing assistance in addressing barriers and securing support, and routinely reaching agreement with collaboratively set goals.

Consumers' expectations about nutrition guidance: the importance of primary care physicians.

To clarify the role of the primary care physician (PCP) in providing nutrition information to the public, we investigated in a random sample of Dutch consumers their referral to 11 nutrition information sources including the PCP, their perceived expertise of these sources, their interest in nutrition information, and their nutritional attitudes and beliefs. Factor analysis over these 11 sources of nutrition information resulted in two factors: noncommercial sources (alpha = 0.70) and commercial sources (alpha = 0.78). Respondents' referral to and perceived expertise on a five-point scale of noncommercial sources was higher than for commercial sources [respectively, 54% compared with 21%, P < 0.0001, and 3.9 +/- 0.6 compared with 2.7 +/- 0.6 (mean +/- SD), P < 0.01]. The individual Spearman correlation coefficient between referral scores and perceived expertise was p = 0.35 +/- 0.36 (mean +/- SD). For most sources, referral to that source was dependent on a higher interest in information about a healthy diet and on perceived expertise of the source. There were three leading noncommercial sources: the PCP, the dietitian, and the Netherlands Food and Nutrition Education Bureau (FNEB). Careful analysis revealed that because of their high referral scores, high perceived expertise, and reach to nearly all segments of the population, PCPs are in a unique position compared with dietitians and the FNEB.

Information sources and strategies of nutrition guidance used by primary care physicians.

We studied the nutrition information seeking behavior of primary care physicians (PCPs) and also PCPs' implementation of different strategies of nutrition guidance of patients. This was done by means of a questionnaire mailed to a nationwide random sample of 1000 PCPs in the Netherlands. The net response rate was 64%. The two most important nutrition information sources for PCPs were a dietitian (72% of respondents) and the literature (34% of respondents). Eighty-five percent of PCPs reported that they were actively involved in seeking nutrition information. For nutrition education of patients, PCPs gave personal information to patients, referred patients to a dietitian, and made publications available in the surgery. As preferred methods of obtaining nutrition information themselves, PCPs listed scientific journals, postgraduate nutrition education, congresses and study days, and publications. Determinants of nutrition information seeking behavior of PCPs as well as their implementation of different strategies of patient nutrition education were identified and discussed. PCPs were familiar with the body mass index, which is encouraging because treatment of overweight and obesity starts with a valid assessment. The findings in this study lead to a prudent positive conclusion about PCPs and nutrition information in practice. From this study and others it can be concluded that there are growing opportunities, challenges, and tools for PCPs to become more actively involved in nutrition guidance of patients.

Perceived relevance and information needs regarding food topics and preferred information sources among Dutch adults: results of a quantitative consumer study.

OBJECTIVE: For more effective nutrition communication, it is crucial to identify sources from which consumers seek information. Our purpose was to assess perceived relevance and information needs regarding food topics, and preferred information sources by means of quantitative consumer research. DESIGN: Based on qualitative studies, a quantitative questionnaire was developed and administered in face-to-face interviews. SUBJECTS: The study population consisted of Dutch adults aged 18-80 y. A stratified sample of 923 adults was taken from the GfK ScriptPanel; 603 respondents completed the questionnaire. RESULTS: Despite high perceived relevance of food topics regarding dietary guidelines (55-78%), most respondents indicated that they did not want more information about these topics (71-74%). Furthermore, our study revealed information needs regarding safety- and health-related food topics (up to 77% in some subgroups). Differences in perceived relevance and information needs were found in subgroups based on gender, age, perceived weight and socioeconomic status. Education offices of the food sector and the family doctor were mentioned for most food topics, who ranked among the highest regarding perceived reliability, perceived expertise, clearness and accessibility. CONCLUSIONS: With respect to five food topics (losing weight, sports and nutrition, lowering cholesterol, carbohydrates and food composition), interested subgroups should receive tailored information. For other groups and food topics, a population-wide strategy should suffice, utilising the preferred information source. If people who are not yet interested become interested through a life event, information on demand can be put into action. SPONSORSHIP: Dutch Dairy Association.

Nutrition guidance by primary-care physicians: perceived barriers and low involvement.

OBJECTIVE: To investigate the activities of general practitioners (GPs) in nutritional matters and the factors that influence their attitudes, knowledge and behaviour, especially perceived barriers. DESIGN: Postal questionnaires (result of focus group discussions and in-depth interviews) were sent to a nationwide random sample of GPs in the Netherlands. SUBJECTS: 1000 GPs, in practice for between 5 and 15 years. MAIN OUTCOME MEASURES: The identification of GPs' perceived barriers to nutritional guidance of their patients, their nutritional attitudes and behaviours. RESULTS: Net response rate was 64% (633/990). GPs perceived smoking to be the greatest health hazard, followed by dietary pattern and genome. 70% expressed considerable interest in the role of nutrition in health. In daily practice nutrition plays a minor role in the work of the GP. 28% of GPs gave daily nutrition information to about 10% of their patients and 48% to about 5% of their patients. It is found that GPs do perceive strong barriers of being involved in nutrition issues during their practice. The most important barriers expressed were: not being trained in nutrition, lack of time to address nutrition issues and the perception that patients lack motivation to change lifestyle and/or dietary patterns. CONCLUSIONS: The involvement of GPs in nutritional matters is very low. The fact that lack of training is considered as the most important barrier is, however, unexpected. This finding offers possibilities for improvement in which in-service courses and inter-active distant-learning programmes on nutrition for GPs should get special attention.

Cross-sectional and longitudinal analyses of nutrition guidance by primary care physicians.

OBJECTIVE: To investigate in primary care physicians (PCPs) the determinants of a nutrition guidance practice ('noticing patients' overweight and guidance of treatment'), as well as their mechanism of action, in a cross-sectional and a longitudinal approach. DESIGN: Mixed longitudinal design. Five years follow up study of a previous cross-sectional study in October 1992. SUBJECTS: A representative sample of 675 Dutch PCPs, in practice for 5 up to 20y. INTERVENTIONS: A shortened version of the Wageningen PCPs Nutritional Practices Questionnaire was mailed to the subjects in August 1997. MAIN OUTCOME MEASURE: To obtain with the LISREL-program a model of the mechanism of action of determinants of the dependent variable 'noticing patients' overweight and guidance of treatment' with an adequate fit of the empirical data, both in the cross-sectional and in the longitudinal approach. RESULTS: The same set of predisposing factors and intermediary factors explains the dependent variable both in two different representative cross-sectional study populations of PCPs, and in a cohort cross-sectional study at two points in time. Two dynamic LISREL-models were developed (the 'determinant-longitudinal approach' and the 'early behaviour longitudinal approach') which explain the dependent variable. The latter model has, as added value, a gain in explained variance. In 5 y time, the dependent variable decreased significantly (P < 0.001). CONCLUSIONS: This study reconfirms that PCPs' nutritional guidance practices are determined partly directly by predisposing factors, and indirectly via driving forces and barriers. However this study also reveals that an important nutrition guidance practice of PCPs, 'noticing patients' overweight and guidance of treatment', shows a significant decrease over the last 5 y. At the same time, two of the four predisposing factors and two of the three driving factors also decreased significantly. As research findings indicate that the role of diet in health and disease becomes of greater influence PCPs need to be activated to apply their responsibility in this field within a multi-faceted approach.

The NECTAR-study: development of nutrition modules for general practice vocational training; determinants of nutrition guidance practices of GP-trainees. Nutrition Education by Computerized Training And Research.

OBJECTIVE: To identify determinants of nutrition guidance practices of general practitioner-trainees (GP-trainees), to investigate whether these determinants differ from those found by experienced general practitioners; to reveal educational directions towards the development of computer-based instruction on nutrition. DESIGN: Cross-sectional study by means of validated questionnaires. SUBJECTS: All GP-trainees in training at the eight university departments for vocational training in the Netherlands in September, 1998 (n = 985). MAIN OUTCOME MEASURES: Reliability of determinants of nutrition guidance practices was calculated by means of Crohnbach's alpha. The mechanism of action of determinants was identified by means of linear structural relationship analysis (LISREL) using a model developed for GPs. RESULTS: Crohnbach's alphas for factors ranged from 0.58-0.90. The empirical GP-trainee-data fitted with the corresponding GP-model on the mechanism of action. CONCLUSIONS: The same predisposing factors, driving forces and barriers as found with GPs were identified with GP-trainees. Comparing the GP-and GP-trainee-models, only minor differences were found in the path coefficients between factors. Lack of nutrition training and education proved to be of great influence on the extent of nutrition information given. The GP-trainee-model will be of use in developing computer-based instruction on nutrition. It is expected that GPs may also benefit from this instruction.

Appraisal of 4 months' consumption of nutrient-dense foods within the daily feeding pattern of frail elderly.

OBJECTIVES: The appraisal and acceptance of micronutrient-dense versus identical regular foods among frail elderly are described. METHODS: Four types of dairy and four types of fruit products, either enriched with multiple micronutrients or not, were consumed by 150 frail elders for 4 months. In the first 2 and last 2 weeks of the intervention, hedonic aspects were assessed. Afterward, evaluation forms were completed. RESULTS: At the start, small but consistent differences existed between the enriched and the regular foods concerning the scores on pleasantness, desire to eat the product, and attitude toward the product. At the end, those ratings dropped slightly or stayed equal. Significant differences between groups emerged from the overall evaluation score: 6.4 plus or minus 1.6 and 7.7 plus or minus 1.7 respectively (p <.001). DISCUSSION: Optimization of the hedonic parameters of nutrient-dense foods and major long-term attention for application in the daily elderly feeding pattern is of essential importance.

Examining the content of weight, nutrition and physical activity advices provided by Dutch practice nurses in primary care: analysis of videotaped consultations.

BACKGROUND/OBJECTIVE: To examine the content of Dutch practice nurses' (PNs') advices about weight, nutrition and physical activity to overweight and obese patients. SUBJECTS/METHODS: A 100 videotaped real-life PN consultations (The Netherlands, 2010/2011) with overweight or obese patients were selected. An observational checklist was developed to assess frequency and content. Personalization of advices was scored, as also the guidelines on which PNs based their advices. Content analysis was used to identify different categories of advices. RESULTS: About one quarter of advices concerned weight, over two-thirds nutrition and one-third physical activity. Lose weight, eat less fat and be more physically active in general were the main categories for each type of advice. Despite high clarity of advices, lower scores were found for specificity and personalization. Very few nutrition advices were provided in combination with physical activity advices. CONCLUSIONS: Weight advices often related to the patient's complaint. PNs seldom set a concrete weight goal. Although benefits of physical activity were discussed, often no practical advices were provided about how to achieve this. Integrated lifestyle advice was not common: advices about nutrition and physical activity were fragmented throughout the consultation. Obesity prevention needs more emphasis in PNs' educational programs.