Does misperception of fruit and vegetable intake adequacy affect progression through the stages of behavior change after nutritional intervention?
Introduction
Fruit and vegetable (FV) consumption promotes health (WHO & FAO, 2005) and lowers the risk of morbidity and premature mortality (Boeing et al., 2012); however, intake remains low worldwide. In Brazil, only 23.7% of adults report eating at least five servings a day (Brasil, 2019). In 2017, FV intake was found to be insufficient in almost all regions of the world, and diets low in fruit (less than 250g/day) and low in vegetables (less than 360g/day) were among the five leading dietary risk factors for morbidity and mortality (Afshin et al., 2019).
Different interventions for improving dietary habits have been proposed. The Transtheoretical Model (TTM) stands out as a promising tool for health promotion and nutrition education, including increases in FV intake (Menezes, Bedeschi, Santos, & Lopes, 2016). The TTM's main pillar is called stages of change, which represent an individual's readiness to modify a certain behavior (for example, to quit smoking or to increase fruit and vegetable intake) (J O Prochaska, Norcross, & DiClemente, 2013). The other pillars are called self-efficacy, decisional balance, and processes of change, which mediate the evolution through the stages of change (J. O. Prochaska & Velicer, 1997).
The five traditional stages of change are called pre-contemplation, contemplation, preparation, action, and maintenance. Individuals in pre-contemplation are not ready to change the target behavior. Those in contemplation are thinking about changing but feel ambivalent about the pros and cons of changing. Individuals in preparation have decided to start changing their behavior in the next 30 days. Those in action have sustained change for up to six months, while those in maintenance have been able to sustain the change for over six months (Prochaska, Diclemente, & Norcross, 1992).
Stages of change can be measured for a variety of health-related behaviors, such as dietary behavior (J O Prochaska et al., 2013). The identification of an individual's stage of change results from assessments based on individual perception of intake adequacy or estimated food intake (J O Prochaska et al., 2013; Toral & Slater, 2009). However, some individuals' perception of adequacy and objectively estimated intake might not match. Thus, two additional stages of change have been proposed: pseudomaintenance (PM), proposed by Steptoe et al. in 1996 (Steptoe, Wijetunge, Doherty, & Wardle, 1996) and non-reflective action (NRA), proposed by Ma et al. in 2003 (Ma, Betts, Horacek, Georgiou, & White, 2003). PM refers to individuals who have a low intake of these foods but believe they eat enough FV (Steptoe et al., 1996), while NRA refers to individuals who meet FV intake requirements but do not recognize their intake as sufficient (Ma et al., 2003).
To move from a stage of change to a more advanced stage, individuals change their self-efficacy and decisional balance (J. O. Prochaska & Velicer, 1997). Self-efficacy represents the extent to which individuals believe they are able to perform the behavior change, while decisional balance means the relative importance given to the pros and cons of changing (J. O. Prochaska & Velicer, 1997).
The existence of misperceived food intake has been reported in different contexts (Bedeschi, Lopes, & Santos, 2016; Carvalho, Menezes, & Lopes, 2018; Dijkstra, Neter, Brouwer, Huisman, & Visser, 2014; Figueira, Lopes, & Modena, 2015; Lechner, Brug, & De Vries, 1997; Lechner, Brug, De Vries, Van Assema, & Mudde, 1998; Ling & Horwath, 2000; Ma et al., 2003; Povey, Conner, Sparks, James, & Shepherd, 1998; Sproesser, Klusmann, Schupp, & Renner, 2015; Steptoe et al., 1996; Toral & Slater, 2009; Toral, Slater, Cintra, & Fisberg, 2006). However, few longitudinal or intervention studies have been done to identify whether and how misperception of FV intake affects the evolution of FV intake (Menezes, Mingoti, Mendonça, & Lopes, 2017; WHO, 2004). Most studies have a cross-sectional (Bedeschi et al., 2016; Carvalho et al., 2018; Dijkstra et al., 2014; Lechner et al., 1997, 1998; Ling & Horwath, 2000; Ma et al., 2003; Steptoe et al., 1996; Toral et al., 2006; Toral & Slater, 2009) or qualitative (Figueira et al., 2015; Povey et al., 1998) design. PM is the most prevalent type of discordant perception (Carvalho et al., 2018; Toral & Slater, 2009) and the one that poses the greatest risk for individuals, as they are exposed to low intake while believing that they eat enough FV; this can hinder their motivation to increase their intake. Furthermore, it is not known whether they can improve their perception of FV intake adequacy when they are exposed to interventions based on the five traditional stages.
Thus, this study aims to describe the effect of baseline pseudomaintenance on the evolution of the stages of change for FV intake in a sample of adult and elderly health promotion service users after a usual TTM-based nutritional intervention.
Section snippets
Study design, setting, and sample
A randomized controlled community trial was carried out with a sample of Health Academy Program (HAP) users in Belo Horizonte, Brazil. HAP centers are part of the Brazilian Unified Health System. In Belo Horizonte, these public health promotion services are usually located in vulnerable neighborhoods and offer free supervised physical activity and health promotion actions for adults and seniors (A. C. S. Lopes et al., 2016).
The trial was carried out according to the Declaration of Helsinki
Results
At baseline, 3414 HAP users from the 18 HAP centers were evaluated (response rate: 90.7% of eligible HAP users; refusals: 3%, n = 112; exclusion: 6.3%, n = 237) and randomized to the intervention group (n = 9 HAP centers, 1483 users) or the control group (n = 9 HAP centers, 1931 users). After intervention, 2241 individuals were reassessed (lost to follow-up: n = 1173, 34.4%). All individuals who were reclassified in non-reflective action at baseline and/or follow-up (n = 644) were excluded from
Discussion
This study identified a high prevalence of pseudomaintenance for FV intake at baseline. Baseline pseudomaintenance was associated with higher odds of progressing to higher stages of behavior change for fruit intake at follow-up. We found no association between baseline pseudomaintenance and stage progression for vegetable intake.
As far as we know, this is the first report of intervention results according to baseline pseudomaintenance for fruit and vegetable intake among adults and seniors.
Conclusions
Individuals in pseudomaintenance for FV intake at baseline have shown different patterns of stage progression for fruit intake and vegetable intake after the usual grouping for TTM-based intervention. Being in PM for fruit at baseline was associated with higher odds of stage progression at follow-up. No significant association was found between being in PM for vegetables at baseline and stage progression at follow-up.
We reinforce the need for additional research regarding the specific stage
Funding
This work was supported by Minas Gerais State Research Support Foundation (Fundação de Amparo à Pesquisa do Estado de Minas Gerais, FAPEMIG) [grant numbers APQ-033376-12, 21618/2013, PPM-00254-15, and a graduate studies scholarship for MCRC] and National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq) [grant number 476686/2013–0, and a research productivity scholarship for ACSL]. The funders had no role in the study
Declaration of competing interest
None.
References (44)
- et al.
Misperception of self-reported adherence to the fruit, vegetable and fish guidelines in older Dutch adults
Appetite
(2014) - et al.
Risk perceptions and health behavior
Current Opinion in Psychology
(2015) - et al.
Decisional balance for health and weight is associated with whole-fruit intake in low-income young adults
Nutrition Research
(2010) - et al.
How can stages of change be best used in dietary interventions?
Journal of the American Dietetic Association
(1999) - et al.
Misconceptions of fruit and vegetable consumption: Differences between objective and subjective estimation of intake
Journal of Nutrition Education
(1997) - et al.
Defining and measuring stages of change for dietary behaviors: Readiness to meet fruit, vegetable, and grain guidelines among Chinese Singaporeans
Journal of the American Dietetic Association
(2000) - et al.
Comparison between two assessment tools for fruit and vegetable intake relative to the 24-h recall
Nutrition
(2017) - et al.
Validated scales to assess adult decisional balance to eat more fruits and vegetables
Appetite
(2010) - et al.
Fruit and vegetable intake: Influence of perceived food environment and self-efficacy
Appetite
(2018) - et al.
Promoting fruit and vegetable consumption: Methodological protocol of a randomized controlled community trial
Contemporary Clinical Trials Communications
(2018)
Assessing the consequences of unrealistic optimism: Challenges and recommendations
Consciousness and Cognition
Comparative optimism about healthy eating
Appetite
Perception of eating practices and stages of change among Brazilian adolescents
Preventive Medicine
Health effects of dietary risks in 195 countries, 1990-2017: A systematic analysis for the global burden of disease study 2017. Lancet
Self-efficacy: Toward a unifying theory of behavioral change
Psychology Review
Stages of change and factors associated with misperceived eating behavior in obese individuals
Revista de Nutrição
Critical review: Vegetables and fruit in the prevention of chronic diseases
European Journal of Nutrition
Marco de referência de educação alimentar e nutricional para as políticas públicas
Vigitel Brasil 2018: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico
Perception versus intake of fruit and vegetables
Revista de Nutrição
Association between perceived food environment and self-efficacy for fruit and vegetable consumption among US adults
Preventing Chronic Disease
Assessing fruit and vegetable consumption among families of users of the Programa Academia da Saúde (PAS)
Revista Brasileira em Promoção da Saúde
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