Page 858 - Cardiac Nursing

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834 PA R T V / Health Promotion and Disease Prevention
The response to dietary intervention is variable and appears re- and feedback can be used to assist patients in the change
lated not only to the specific fatty acid composition of the diet but process. 100–102
to the level of plasma lipids. Persons with the higher lipid levels Daily logs of food patterns, eating habits, environmental set-
usually experience the greatest response to dietary interventions. 90 ting, and self-efficacy measures provide an opportunity for the pa-
Before initiating dietary change, an assessment of the patient’s tient to evaluate his or her own behavior and to receive feedback
current dietary pattern and usual eating habits is necessary. Di- on specific successes or assistance in identifying undesirable pat-
etary assessments are based on subjective reports and are predis- terns or trends. The antecedents to the behavior can be examined
posed to problems of recall accuracy and reliability. Review arti- for positive or negative influences on dietary behavior. Small
cles on dietary assessment issues suggest that food frequency portable computers are available that can record dietary intake
inventories or careful diet history provide the most accurate in- and give an immediate nutrient analysis. This type of device in-
formation on usual eating patterns. 91,92 Assessment tools are re- corporates the techniques of self-monitoring, evaluation, and
ported in the literature or can be obtained from agencies such as feedback and, in some cases, can supply alternative choices. Less
the American Dietetic Association, American Heart Association, sophisticated written records that detail the food item, amount,
the NCEP, the Preventive Cardiovascular Nurses Association, or and type of preparation have also been shown to be adequate for
product manufacturers. 93 the purposes of monitoring and changing behavior. It is not un-
usual for record-keeping alone to lead to altered behavior. Record
Dietary Change Strategies analysis can also be useful in determining appropriate goals.
Many behaviorists view goal setting as a key element. The goal
For most patients, recommendations for dietary change are not should be defined by the patient and should be one that is small,
sufficient to effect long-term dietary change. Substantial knowl- specific, and measurable. Nurses can assist the patient through the
edge must be acquired and specific behavior skills must be process, ensuring that these key goal attributes exist.
learned and practiced. Required knowledge should include an A variety of aids have been developed to assist personal moni-
understanding of the relationship between dietary fat, dietary toring and evaluation of food choices. 103,104 Booklets listing the
cholesterol, and blood cholesterol; defining reasonable expecta- grams of fat for typical portions of commonly consumed foods
tions for dietary change; understanding the differences in the have been successfully used for this purpose. 105 These booklets
quality of fats; ability to read and interpret food labels; sufficient usually are pocket-sized and are easily carried while grocery shop-
knowledge about food items to estimate fat content of unlabeled ping or to restaurants, and they usually include a diary for record-
items; and knowledge of food preparation methods that affect fat ing personal daily intake. Behavior can be reinforced using evalu-
content. Because eating is a part of our social environment, the ation and feedback techniques.
behavioral skills must be adapted to a variety of social settings, Feedback can be provided through analysis of food records and
such as travel, eating out, celebrations, and the work environ- by measurement of blood lipids. It is possible to achieve plasma
ment. Patients should practice label reading and menu selections cholesterol reductions of 15% to 20% with adherence to a low-fat
and questioning food preparers or servers. Anticipatory responses and low-cholesterol diet. However, given the individual variability
for avoiding high-fat foods in social situations should be explic- of response, caution should be exercised in providing feedback
itly identified. Adapting recipes and developing grocery shopping based totally on plasma cholesterol measures. Feedback and re-
lists that include brand-name selections are also useful skills to wards based on dietary behaviors are likely to provide more posi-
learn. tive and long-lasting reinforcement.
Computer modeling techniques have been used to examine
the effect of dietary fat reduction strategies to determine the most
effective strategy for meeting dietary goal. 94 The strategies in- WEIGHT CONTROL AND
cluded substitution of low-fat counterparts for high-fat items, re- LIPID MANAGEMENT
duction in quantity of high-fat foods, replacement of high-fat
foods with other types of foods (e.g., beans for meat), and modi- The prevalence of obesity in the United States has increased since
fying preparation techniques (e.g., broiling instead of frying). For the late 1970s. It is estimated that more than one third (65 mil-
men, the strategy of replacement was the single strategy that met lion) of adults have a body mass index (weight in kilograms di-
the dietary goals. No single strategy was effective for women. The vided by height in meters squared) greater than 31 and would be
results suggest that the most significant changes occur using com- considered severely obese. 106 Because both LDL and the inci-
binations of dietary strategies. Education alone is unlikely to fa- dence of CVD are reduced in people who maintain a normal body
cilitate dietary change. Studies examining educational interven- weight, these data are alarming. Studies examining weight loss
tions have found only a small relationship between knowledge, have reported varying effects on lipid profiles. A meta-analysis of
attitudes, and dietary behavior. 95 70 studies examining the effect of weight reduction on lipopro-
When behavioral interventions were combined with educa- teins found that a 1-kg reduction in weight was associated with a
tional strategies, more positive dietary outcomes were ob- 0.05-mmol/L decrease in total cholesterol (1 mmol/L 38.67 mg/
served. 96–98 Behavioral strategies are based on the principles of so- dL). 107 Significant decreases in LDL and triglyceride levels were
cial learning theory. 99 Social learning theory principles include also found.
examining the antecedents of the behavior (expectations and val- The effect of weight loss on HDL varies, generally decreasing
ues placed on the behavior outcome), the skills and knowledge during the active weight-loss period and increasing after a period
needed to perform the behavior, and the reinforcement contin- of stable reduced weight. Krauss et al. studied the effect of four
gencies associated with the behavior (rewards, feedback, and eval- diet patterns (a 54% carbohydrate, low-saturated fat diet, a 39%
uation). Many behavioral techniques, such as self-monitoring, carbohydrate, low-saturated fat diet, a 26% carbohydrate, low-
goal setting, defining alternatives and choices, evaluation, rewards, saturated fat diet and a 26% carbohydrate, high-saturated fat diet)