British Journal of Nutrition (2000), 83, Suppl.

1, S165–S168 S165

How to implement dietary changes to prevent the development

Annie S. Anderson
Centre for Applied Nutrition Research, Matthew Building, University of Dundee, Dundee, UK

Changing dietary intake is a major challenge to individuals, households and the general public.
Promoting the consumption of diets that are low in fat and high in fruits, vegetables and starchy
carbohydrate, and managing overweight and central obesity, are important dietary strategies for
the prevention of metabolic syndrome. Educational, behavioural and motivational tactics are
required to help people achieve overall dietary change. These strategies might usefully be based
on intervention models which incorporate behavioural theories and goals through personal,
multiple contact with individuals or in small groups, using active involvement and specific
behaviour-change strategies. Two particular aspects, namely the impact of computer-generated,
personalized nutrition education and social support networks (e.g. family, health centre and
community) provide useful adjuncts to traditional dietary counselling and might usefully be
incorporated into diet- and lifestyle-change programmes for community-based and individual-
ized approaches for disease prevention. The use of moderate energy-deficit diets, modest targets
for weight loss (and maintenance) which can be sustained over the long term, and increased
physical activity probably offers the most feasible approach for intervention aimed at reducing
overall body weight.

Dietary intervention: Obesity: Behavioural theories

Prevention – population and individual change little is known about compliance outside the trial situation
or adherance to prevention programmes. A comprehensive
Changing dietary intake for disease prevention has been
approach to preventing insulin-resistance syndrome might
advocated for many medical conditions, but there is little
usefully combine population-based strategies through nutri-
information on effective approaches to altering food beha-
tion policy implementation, selective prevention (directed at
viour in individuals, households and the community at large.
subgroups of the population with an above-average risk of
Nutritional strategies for the prevention of insulin-resistance
developing insulin-resistance syndrome), and targeting
syndrome in the community are similar to national food-
high-risk individuals.
based dietary guidelines for health promoted by most
European countries (Williams et al. 1999), with additional
Effective approaches to dietary change
approaches necessary for the management of overweight
and central obesity. Effective approaches to healthier eating in the general popu-
Through an integrated nutrition policy approach, a lation have recently been reviewed by Roe et al. 1997 who
number of Nordic countries such as Finland have succeeded demonstrate that ‘despite the difficulties inherent in achiev-
in reducing fat intake and increasing intake of fruits and ing dietary change in the general population, healthy eating
vegetables in the general population over the past few interventions in a variety of settings were effective’. Out-
decades (Pietinen et al. 1996). However, there appears to comes in the studies which were reviewed include a reduc-
be little evidence that the prevalence of overweight has tion in blood cholesterol and a reduction in dietary fat
diminished, suggesting that additional approaches are intake. The authors conclude that interventions directed at
required to reduce total energy intake and increase physical healthy eating should, at most, address one related risk
activity. Encouraging results from the Oslo Diet and Exer- factor such as exercise. In the context of insulin-resistance
cise Study (Torjesen et al. 1997) on weight loss after 1 year syndrome this is an important message and supports the
show that a diet and exercise intervention may help to development of programmes that tackle both eating and
reverse development of insulin-resistance syndrome, but activity behaviours.

Corresponding author: A. S. Anderson, fax +44 (0)1382 200047, email [Link]@[Link]

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 S166 A. S. Anderson

The main characteristics of the effective healthy eating Table 1. Strategies for social support in dietary change programmes
interventions reviewed by Roe et al. (1997) provide a useful
basis for the design of dietary programmes for high-risk Support Examples
individuals in a wide range of settings, including primary
care, community and the workplace, and are as follows: Couples Identify personal actions of partner
Contract to agree to provide practical
X using an intervention model incorporating behavioural support
theories and goals rather than one based solely on the Family Group activities
Family interactions that influence food
provision of information consumption
X intervention methods emphasizing personal contact with Partnership/buddy Daily telephone contact
individuals or in small groups, using active involvement Discourage unacceptable behaviour
and specific behaviour-change strategies Support group Monitor each other’s weight
X some degree of personalization of the intervention to Use group problem solving
individual characteristics, either by contact with trained
personnel or use of individualized printed materials
A major feature of any long-term disease prevention
X the provision of feedback on individual changes in
strategy should involve children. The focus of intervention
behaviour and risk factors
in children must lie with initiating healthy eating and
X multiple contact over a substantial period of time
activity habits in early life, including breast-feeding and
X encouragement of support for individual dietary change
avoiding solid foods before 4 months of age, both of which
by involving family members, colleagues and others.
have been demonstrated to be associated with greater levels
The traditional healthcare approach of individual counsel- of body weight in childhood (Wilson et al. 1998; von Kries
ling interventions shown to be effective was often relatively et al. 1999). In terms of body composition, programmes are
intense and required substantial resources. In terms of cost- needed that aim at increasing lean body mass as children
effectiveness it may be necessary to consider a range of increase in age, allowing for physical and intellectual
communication methods. A combination of educational, development.
behavioural and motivational strategies is required to help
people achieve dietary change (Anderson et al. 1998), and
Effective approaches to weight loss and maintenance
traditional approaches based solely on ‘information transfer’
are unlikely to be successful. Moving towards a client- Central to the prevention of insulin-resistance syndrome is
centred approach, where some or most of the control over the avoidance and management of overweight, especially
dietary behaviour is directed by the patient, offers consider- central obesity. There are no long-term studies which demon-
able scope for working in partnership towards behaviour- strate effectiveness of obesity prevention or weight main-
change strategies that can be utilized for a range of personal tenance, but there is a general consensus on management
behaviours. Once the patient has identified the dietary habits of the overweight (WHO, 1998). The dietary component of
which he/she wishes to control, positive feedback methods weight management programmes needs to be set in the con-
can help to support further actions and improve self esteem. text of a system which builds in social support and behav-
One approach which offers a practical route for assisting ioural and exercise management. The combination of a
the delivery of interventions is computer-generated, personal- reduced-energy diet and increased physical activity is
ized materials. This method allows messages to be tailored recommended by the US NIH (1998) on the grounds that
to individual behaviours and circumstances. Studies based it produces weight loss which may also result in decreases in
on behaviour change theory which employ this methodol- abdominal fat. Behavioural theory-based programmes which
ogy indicate that computer-tailored nutrition education is incorporate motivation and readiness to implement lifestyle
more likely to be read, remembered and experienced as changes enable dietary and activity goals to be negotiated
personally relevant and may have greater impact on moti- between professional and patient, allowing for modest
vating people to change their diet (Brug et al. 1999). weight loss or maintenance over a sustained period. Relat-
However, eating and drinking are so strongly influenced ing dietary advice to social circumstances (especially with
by social behaviour that contact with nutrition educators and consideration of financial resources, shopping and culinary
computers are unlikely to achieve dietary alterations with- skills, and ethnically appropriate choices) and psychological
out support from the people that most strongly influence well-being are further considerations for individual goal
food choice, such as family members, colleagues, local setting.
leaders and wider community endorsement. Strategies for Setting realistic weight management goals is essential for
increasing social support in dietary change interventions, as the self esteem of both patient and professional. In preven-
highlighted by Kelsey et al. (1997), are outlined in Table 1. tion terms, a body weight which is kept constant over a
Support methods which are practical in the clinic setting decade as a result of a weight management programme
(e.g. bringing the whole family together) may be difficult represents a successful outcome. Substantial benefits can
to undertake but again need to be directed by the patient result from moderate weight losses, e.g. 5–10 kg in 1 year
to suit his/her circumstances. Societal attitudes which (Goldstein, 1992), if these can be sustained. It is important
accept dietary change as a positive step rather than to recognize that most patients are unable to continue losing
something to be forgotten, neglected or ignored whilst weight for longer than 12–16 weeks, and further efforts may
eating in company also provides a strong background for result in failure contributing to low self esteem and low
individual change. perceived behavioural control.

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 Implementing dietary change S167

The value of using an individualized, moderate energy have been limited, but long-term outcomes in children are
restriction for weight loss over the more conventional stan- more promising when family-based therapy approaches
dardized dietary regime has been demonstrated by Frost have been employed (Epstein et al. 1994)
et al. (1991). In their comparative study they counselled
patients on individualized dietary prescriptions of around
Designing a programme for the prevention of
2⋅2 MJ per person below estimated energy expenditure. A
insulin-resistance syndrome
mean prescription of 7⋅1 MJ/d over 3 months produced
significantly better results – a 5⋅0 kg weight loss compared A cost-effective lifestyle programme for the prevention of
with the 3⋅0 kg loss achieved with a standard 4⋅6 MJ/d insulin-resistance syndrome targeting high-risk individuals
approach. The results contrast with predicted weight loss of has yet to be developed. Designing a programme of dietary
6 and 13⋅2 kg, respectively, which should have been achieved change that is effective in achieving appropriate nutrient
if subjects had adhered completely to the prescriptions. composition and avoiding central obesity, that can be sus-
This individualized approach also enables the com- tained and transferred within different sectors of the popula-
position of the diet to be clearly defined by translating the tion, is a crucial part of lifestyle change. The following steps
energy prescription into a diet plan using food exchanges. need to be considered in design:
One approach now used nationally by Scottish dieticians in
obesity management is an exchange system using ‘bread (1) How can lifestyle change be prioritized (e.g. should an
& cereals’, ‘fruit & veg’, ‘meat & fish’ ‘fat & sugary’, ‘milk individual stop smoking before dietary change)?
& dairy’ groupings ensuring , 30 % energy from fat. (2) How can diet and exercise change be integrated within
Advising on this exchange basis allows an appropriate a long-term strategy?
energy composition to be attained irrespective of weight (3) What energy value and macronutrient composition is
loss. Saturated fats, sugar and alcohol intake are limited, appropriate for high-risk individuals using an indivi-
thus helping to achieve dietary patterns consistent with dualized moderate energy deficit approach?
general healthy-eating guidelines and therefore suitable (4) What is the underlying behavioural theory for lifestyle
for the entire household. change (e.g. Stages of Change model where interven-
Adhering to a weight-loss dietary regimen needs to move tions are tailored according to people’s readiness to
beyond nutritional adequacy to practical considerations change)?
including dietary patterns such as meal size, meal frequency (5) What counselling is required for patient education on
and meal timing, and food shopping and preparation. The food choices, preparation, cooking and dietary patterns?
importance of how to achieve healthy food choices when (6) How can interventions be personalized (e.g. computer
eating outside the home or when limited time and resources feedback) and interactive (e.g. addressing problems,
are available for meal preparation are now considered discussing and negotiating alterations)?
essential components of dietary advice. Clearly such an (7) What are the resources available to provide profes-
approach cannot be achieved by simply distributing a diet sional (e.g. professional or trained lay staff) and non-
sheet, but time for repeated contact with health profes- professional (e.g. family, friends) support for lifestyle
sionals is required to educate and motivate the high-risk change? What follow-up support, feedback and inter-
individual and family. action are available for individuals?
Using behavioural modification tactics to help patients (8) What strategies are available for maintaining weight
regain control of eating habits (whether for weight loss or loss and diet of appropriate composition?
healthy eating) is considered a useful support to achieve
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q Nutrition Society 2000

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