Health Education Research Advance Access originally published online on November 30, 2006
Health Education Research 2007 22(5):718-726; doi:10.1093/her/cyl152
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Factors influencing the dietary response to a nutritional intervention promoting the Mediterranean food pattern in healthy women from the Québec City metropolitan area
Institute of Nutraceuticals and Functional Foods, 2440 Hochelaga Blvd, Laval University, Québec, Québec, Canada G1K 7P4
* Correspondence to: S. Lemieux. E-mail: Simone.Lemieux{at}aln.ulaval.ca
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Abstract |
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 Top Abstract IntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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The purpose of this study was to evaluate the influence of sociodemographic characteristics and baseline food habits on the dietary response to a nutritional intervention promoting the Mediterranean food pattern and maintenance of dietary modifications in 73 healthy women. The 12-week nutritional intervention in free-living conditions consisted of two group courses and seven individual sessions with a dietitian. A follow-up visit was performed 12 weeks after the end of the intervention (week 24). A Mediterranean dietary score was derived from a food frequency questionnaire, administered at 0, 6, 12 and 24 weeks. Marital status, socioeconomic level, educational level and household size did not seem to influence the dietary response, whereas women without children followed more closely dietary advice than women with children (OR, 3.6; 95% CI, 1.3–10.0). Planning food purchases in function of weekly discounts was also associated with better dietary response to the intervention (OR, 3.3; 95% CI, 1.3–8.8). Nutritional intervention promoting the Mediterranean food pattern was effective in modifying food habits of healthy women. The fact of having children or not and food purchase habits seem to influence the response to a nutritional intervention promoting the Mediterranean food pattern.
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Introduction |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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Results from the Seven Countries Study have clearly demonstrated that the 15-year mortality rate from coronary heart disease (CHD) in Southern Europe, where a Mediterranean diet was consumed, was 2- to 3-fold lower than that in Northern Europe or United States [1]. CHD is a major health problem in North American countries. Nutritional intervention aims generally at producing permanent favourable dietary changes to consequently improve risk factors involved in CHD. Following nutritional intervention, many individuals are able to modify their food habits but generally these changes are not, in the long-term, successfully maintained [2–5]. The efficacy of a nutritional intervention to modify several risk factors for CHD in the long-term is related to the compliance of subject [2–6]. Very few studies have tried to evaluate how different characteristics including educational level, having children or not, economic status and food purchase habits could influence the ability to maintain food habits following a nutritional intervention.
The extent to which Canadians may be able to modify and maintain their food habits towards the Mediterranean food pattern is unknown. Nutritional interventions undertaken in free-living uncontrolled conditions imply that participants modify their food habits following dietary advice and professional support and continue to buy their foods and cook their meals. In free-living conditions, other factors may modulate the response to the dietary intervention such as cultural, socioeconomic, familial and personal factors. In this study, our objective was to examine whether sociodemographic characteristics and baseline food habits of the study participants modulate the dietary response following a nutritional intervention promoting the Mediterranean food pattern in free-living conditions and explain the maintenance of dietary modifications in French-Canadian women. For that purpose, we studied a group of healthy free-living women from the Québec City metropolitan area, aged between 30 and 65 years.
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Subjects and methods |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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Subjects
Women from the Québec City metropolitan area were recruited through the Laval University newspaper during the summer of 2001. Women included in the study were aged between 30 and 65 years. To be eligible, women had to be free from metabolic disorders requiring treatment, to have stable body weight for at least 3 months prior to the start of the study and to be in charge of food purchases and meal preparation most of the time. Women eligible for this study were not consuming a typical Mediterranean diet prior to the study. One hundred and twenty eight women were invited to a screening visit for an evaluation of their food habits. Among this initial group of women, 94 were found to be eligible according to the above criteria. Seventy-seven women signed the informed consent form, which had been approved by the Ethics Committees of Laval University. Three women left the study for personal considerations. Therefore, 74 women completed the nutritional intervention. One woman did not complete the food frequency questionnaire (FFQ) at week 12. Thus, we have complete data for 73 women at week 12. In addition, 11 of these 73 women did not show up at week 24 for their follow-up visit.
Intervention
The study was conducted in two phases. The first phase started in August 2001 and the second phase began in January 2002. Each phase was conducted using a similar 12-week intervention design. The nutritional intervention spanned over a 3-month period. The intervention included two group sessions with eight participants per group. The first group session took place during the first week of the intervention. During this 2-h session, the registered dietitian explained the major principles of the Mediterranean diet and health benefits associated to this food pattern. Four weeks after the beginning of the intervention, participants were invited to a Mediterranean cooking lesson in which they had to produce a complete meal.
Individual sessions took place during the first, sixth and 12th weeks of the intervention in order to evaluate the dietary changes and to select further objectives for increasing the adherence to the Mediterranean food pattern. During individual sessions, the registered dietitian used the FFQ and the Mediterranean food pyramid to identify and promote dietary changes to be undertaken. Suggested modifications were always adapted to the participant's food preferences in order to personalize the objectives. Unannounced qualitative 24-h recalls were performed by telephone at weeks 2, 4, 8 and 10. The objective of these recalls was to provide support and to reinforce the key principles of the Mediterranean diet. Three registered dietitians were trained to provide a standardized intervention. The same dietitian provided the two group sessions for all groups included in the study. The participant always met with the same dietitian during the individual sessions. A follow-up visit was performed 12 weeks after the end of the nutritional intervention (week 24). During that session, the FFQ was administered in order to evaluate the long-term effect of the nutritional intervention program promoting the Mediterranean food pattern. Finally, dietary response to the nutritional intervention was established as the change in the Mediterranean score between weeks 0 and 12, whereas maintenance was determined as the change in the Mediterranean score between weeks 12 and 24.
FFQ and Mediterranean dietary score
A validated administered FFQ was completed at screening (t = 0) and then at weeks 6, 12 and 24 [7]. Briefly, the FFQ was administered by a registered dietitian and is based on typical foods, which are available in Québec. It contains 91 items and 33 subquestions. Participants were questioned about the frequency of intake for different foods during the last month and were asked to report the frequency of these intakes in terms of days, weeks or months. A partial score varying from 0 to 4 was attributed to each of the 11 components of the pyramid. Components of the Mediterranean pyramid are grains; fruits; vegetables; legumes, nuts and seeds; olive oil; dairy products; fish; poultry; eggs; sweets and red meat/processed meat. The Mediterranean dietary score (MedScore) could therefore vary between 0 and 44 points [8]. Women eligible for this study were not consuming a typical Mediterranean diet prior to the study. Therefore, eligible women were those with a MedScore at screening that was below an arbitrary value of 27.
Anthropometry
At weeks 0, 6, 12 and 24, body weight, height, waist and hip circumferences were measured according to the procedures recommended at the Airlie Conference on the Standardization of anthropometric measurements [9] and body mass index (BMI) was calculated.
Questionnaires to assess factors influencing dietary response to the nutritional intervention and maintenance of dietary changes
Questionnaires were completed by each participant at weeks 0, 6, 12 and 24 of the nutritional intervention to assess factors influencing dietary response to the nutritional intervention and maintenance of dietary changes. Questionnaires were separated into three parts: (i) Information on socioeconomic variables was collected at week 0 only: education level, average annual family income, marital status, number of children and type of job; (ii) Information about the stages of change according to the transtheoretical model (TTM) developed by Prochaska and DiClemente [10] (week 0 only). Participants were classified in the following stages: pre-contemplation, contemplation, preparation, action and maintenance. Classification into these stages of change was based on the answers obtained to the following question: 'Do you intended to bring changes in your diet?' (iii) Information that was more closely related to food habits was also collected at weeks 0, 6, 12 and 24: usual time spent for cooking, weekly food purchase frequency, frequency of meals eaten at the restaurant, type of restaurants usually attended, planning food purchases in function of weekly discounts and time spent weekly for food purchases. Moreover, at weeks 6, 12 and 24, some questions were added to measure the effect of the intervention on some of the variables assessing changes in food habits, e.g. time spent for cooking according to the principles of the Mediterranean diet. The whole questionnaire administered at week 0 was pretested on a group of 30 women from the Quebec City metropolitan area, and presenting the same age range as participants of the present study.
Nutritional analysis
Evaluation of nutrient intakes derived from food records was performed using the Nutrition Data System for Research software version 4.03, developed by the Nutrition Coordination Center, University of Minnesota, Minneapolis, MN, Food and Nutrient Database 31, released in November 2000 [11]. This database includes >16 000 food items for which the complete nutritional value of 112 nutrients is included. Intakes from vitamin and mineral supplements were not included in the present analysis, which focused on dietary nutrients only.
Statistical analyses
Data collected at the beginning (week 0) and after weeks 6, 12 and 24 were compared using analysis of variance for repeated measures to identify time effects. In the presence of significant time effects, contrast analyses were used to determine precisely the location of the significant differences. Since changes in MedScore or partial score were comparable at weeks 6 and 12, only values at week 12 are presented. Logistic regression analyses were conducted in order to examine the association between the sociodemographic characteristics of the participants, their food habits at baseline and the dietary response to the nutritional intervention. The change in the MedScore between weeks 0 and 12 was dichotomized using the median of the distribution (+7 arbitrary units) and used as the dependent variable in these analyses. Student t-tests were performed to compare the MedScore and changes in the MedScore between these two groups. Dietary changes measured between weeks 12 and 24 were used to assess maintenance. Data at week 24 were analysed on an intention to treat basis including all participants who completed the 12-week nutritional intervention. A total of 62 participants came to the follow-up visit (week 24). Baseline values were carried out for participants with missing data at week 24. In addition, participants were also divided on the basis of changes in MedScore between weeks 12 and 24 (maintenance) using the median of the distribution (–3 units). All analyses were performed with the SAS statistical package version 8.02 (SAS Institute, Cary, NC, USA), and the significance level was set at P = 0.05.
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Results |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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Table I presented the demographic characteristics of the study participants. As shown in Table I, a majority (71%) of women was married. Table I also shows that a majority of participants (64%) had a university degree of education. Ninety-two percentage of women were employed, and 79% were employed full time. Moreover, 65% of the study participants had children. Household size varies from one (18.7%) to five persons (6.7%) (Table I). When considering that usually 14 meals per week have to be prepared (lunch and diner every day of the week), 16% of women prepared all meals, 36% prepared between 10 and 12 meals, 31% between seven and nine meals, 11% between four and six meals and 7% between one and three meals. According to the TTM, 1.3% of women were classified in pre-contemplation state, 24% in contemplation, 47% in preparation, 24% in action and 4% in maintenance stage.
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We have reported the changes in the MedScore and in CHD risk factors in previous publications [8,12,13]. As shown in Fig. 1, the MedScore increased significantly after 12 weeks of nutritional intervention (from 21.1 ± 3.6 at baseline to 28.8 ± 4.5 at week 12). At week 24, MedScore was significantly decreased (26.0 ± 4.6) compared with the value measured at week 12 (P < 0.0001) but was still significantly higher than that at baseline (P < 0.0001).
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Increase in MedScore during the intervention (between weeks 0 and 12) was negatively and significantly associated with decrease in the MedScore during follow-up (between weeks 12 and 24) (r = –0.36, P = 0.004) (Fig. 2). Moreover, MedScore at week 0 was not significantly associated with MedScore at week 12, but was positively associated with MedScore at week 24 (r = 0.44, P < 0.0001). MedScore at week 0 also correlated with changes in MedScore in response to the nutritional intervention between weeks 0 and 12 (r = –0.45, P < 0.0001), but was not associated with changes that occurred in the MedScore between weeks 12 and 24.
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Table II shows differences in the MedScore at weeks 0, 12 and 24 between two groups of women formed on the basis of changes in the MedScore between weeks 0 and 12. Women who increased the most their MedScore in response to the intervention (changes in MedScore >7) had a MedScore at baseline significantly lower than other women (P = 0.01). However, women who increased the most their MedScore between weeks 0 and 12 experimented a larger decrease in MedScore between weeks 12 and 24 than other women (P = 0.0007) but still had significantly higher MedScore at week 24 than the group displaying a smaller increase in MedScore in response to the intervention (Table II).
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In order to determine the effects of sociodemographic characteristics and food habits at baseline on the dietary response to the nutritional intervention, logistic regression analyses were performed. Educational level, annual family income, employment status, marital status or household size did not have an effect on the response to the intervention promoting the Mediterranean diet (not shown). Women without children improved significantly more their dietary habits than women with children [odds ratio (OR) for having a MedScore increase by >7 arbitrary units, 3.6; 95% CI, 1.3–10.0] (Table III). Moreover, women who planned their food purchases as a function of weekly discounts at the beginning of the study were also more likely to show a greater increase in their MedScore than those who did not (OR, 3.3; 95% CI, 1.3–8.8) (Table III).
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Finally, sociodemographic characteristics and food habits at baseline did not affect the maintenance of the dietary habits following the nutritional intervention. Also, stages of change according to the TTM model did not appear to influence dietary response to the intervention and maintenance of dietary changes performed.
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Discussion |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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Our study was conducted in a group of free-living healthy women in whom we promoted the adoption of the Mediterranean food pattern. We examined potential factors that could influence the dietary response to the nutritional intervention and maintenance of dietary changes performed over a 6-month period. Our results indicated that women without children and women who planned food purchases in function of weekly discounts respond better to the intervention.
It is well established that Mediterranean food pattern is associated with a lower prevalence of CHD among Mediterranean [14] and non-Mediterranean population [15,16]. We have previously demonstrated that our intervention may beneficially affect low-density lipoprotein (LDL) cholesterol and apolipoprotein B concentrations [8], LDL peak particle diameter in women with a small LDL peak particle diameter [12], circulating oxidized low-density lipoprotein particles [13], as well as body weight and waist circumference [8]. However, implementing Mediterranean diet in a non-Mediterranean population is challenging and therefore it is useful to understand factors that may influence adherence in that context. Also, only few studies have measured the effectiveness of a dietary intervention on a long-term maintenance of dietary habits [2–6]. Our results showed that educational level, socioeconomic status and marital status did not affect the response to our nutritional intervention. However, according to data from the Canadian population [17], our sample underrepresented single women (17.0% as compared with 25.4%), overrepresented working status (92.0% versus 59.6%) and university educational level (64.0% versus 17.2%) and underrepresented women having annual family incomes <CAN$20 000 (0% versus 53.0%). This might have influenced results obtained.
Many factors may affect the ability of individuals to adhere to a new diet and maintain new dietary habits. In our study, one of them appears to be planning food purchases in function of weekly discounts. No significant differences were observed between women planning food purchases in function of weekly discounts and those who were not for age, marital or parental status, BMI or changes in BMI in response to the nutritional intervention. It is likely that, other characteristics or personality traits, not measured in this study, may be related to the habit of planning food purchases in function of weekly discounts. For example, we could speculate that these women were generally more organized, and that they were more likely to plan their meals, physical or housework activities. These women may have the ability to adapt their meals in function of weekly discounts and we could hypothesize that these women were more flexible in their meal preparation and thus could adhere more closely to the Mediterranean diet. We could also hypothesize that planning food purchases may be an indication of conscientiousness-related traits which include personality traits such as self-discipline, achievement striving and deliberation [18]. Previous findings indicated that conscientiousness was related to a closer adherence to a cholesterol lowering [19] or to a weight-loss program [20]. Moreover, results from a recent meta-analysis suggested that conscientiousness-related traits were positively related to healthy behaviours including diet [18]. These hypotheses concerning the impact of personal factors on adherence to a nutritional intervention clearly need further investigation.
Interventions involving healthy participants, such as ours, have the challenge of motivating individuals to change behaviour without immediate apparent health benefits. In fact, two recent reviews indicated that intervention with high-risk populations were more likely to report significant intervention effects [21,22]. The review by Ammerman et al. [21] also indicated that two intervention characteristics were associated favourably with modifying dietary behaviour: goal setting and small groups. Accordingly, the design of our study included group sessions and individual targeted objectives. These could have largely influenced outcomes of our intervention. In fact, MedScore at week 0 was not associated with MedScore at week 12. This suggests that adherence to the Mediterranean food pattern is influenced more by the intervention design than by the baseline food habits. Our results also indicate that women who had a better dietary response to the intervention between weeks 0 and 12 experimented a larger decrease in MedScore between weeks 12 and 24. However, their score at week 24 remained higher than their score measured at baseline and the score measured at week 24 in the group displaying the smallest increase in the MedScore in response to the intervention. This suggests that when professional support declines, habitual food habits and other environmental factors may favour changes towards preintervention values but that overall improvements in dietary habits are more important if dietary changes are more significant during the intervention phase.
Women were asked about what could have helped them to maintain their new dietary habits between weeks 12 and 24. Thirty percentage of women indicated that attending a group session between weeks 12 and 24 would have helped them, 23% indicated that a phone call by the nutritionist may contribute to a better maintenance and 17% indicated that an individual session with the nutritionist could be helpful to maintain dietary changes performed during the intervention. Therefore, it could be suggested that extending the duration of the intervention could result in a better long-term maintenance. This should be tested in a further study.
Previous studies showed that intervention in one member of the family influences food choices of other family members [23]. It is still generally accepted that the family diet is the woman domain. Most of the time, she is responsible for shopping, cooking and organizing family meals [24]. Mothers are found to prefer family peace and harmony above conflicts about healthy food [24]. Food preferences of the other family members are often taken into account more than their own preferences or their intention to cook healthier foods [24]. From this point of view, nutritional intervention and advice directed at mother in their role as presumed 'controllers' of the family diet are likely to be less effective than what can be expected, if the process of decision making in the family is ignored [25,26]. Accordingly, our results suggest that women having children are less likely to adhere to dietary recommendations. In our study, the potential impact of family factors was not considered in the design of our intervention and this is an issue that should be taken into account to improve the response to the intervention in further studies.
The TTM was originally developed for addictive behaviour; it has been applied to a wide range of behaviours such as dietary habits [27,28]. Critics have arisen about the applicability of the model in more complex behaviour such as diet [29]. John et al. [27] suggested that documenting barriers associated to dietary changes may conduct to better adherence than tailored intervention accordingly to stages of changes. In our study, participants were not selected according to their stages of change and the intervention was not adapted to the stages of change. Our results indicate that women responded to the dietary intervention independently of the stages of change at baseline which is concordant with the conclusions of the work of John et al. [27]. A possible explanation for this effect is that proposed categories of TTM were probably not discriminating enough for our sample of already motivated women. However, this hypothesis needs to be investigated.
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Conclusion |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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In conclusion, having children or not and food purchase habits seem to influence the response to a nutritional intervention promoting the Mediterranean food pattern in women in a North American context; these factors may be considered in subsequent studies. Further studies are needed to investigate the influence of familial factors and food habits on adherence to dietary recommendations in order to improve the success of nutritional interventions.
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Conflict of interest statement |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionConclusionConflict of interest statementAcknowledgementsReferences |
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J.G. is a recipient of a studentship from the Fonds de la recherche en santé du Québec, S.L. is a research scholar from the Fonds de la recherche en santé du Québec and B.L is the recipient of a Canada Research Chair in Nutrition and Cardiovascular Health, Functional Foods and Cardiovascular Health from the Canada Research Chair Program. This study was partly supported by the Canada Research Chair in Nutrition and Cardiovascular Health, Functional Foods and Cardiovascular Health from the Canada Research Chair Program. The authors express their gratitude to the participants for their motivation and implication throughout the study. We acknowledge the contribution of Nancy Gilbert M.Sc, R.D., Geneviève Nadeau, M.Sc, R.D. and Amélie Charest M.Sc, R.D. to the nutritional intervention, Annie Lapointe R.D for data analysis and thank Danielle Aubin for nursing assistance.
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References |
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Received on December 7, 2005; accepted on September 14, 2006
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