Transtheoretical model stages of change diet

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Background

Literature has shown wonderful tendency of inadequate dietary aliment among youth, consequently, nutritional interventions are required.

The transtheoretical representation (TTM) classifies individuals based force their readiness to change. That model is widely used put health education interventions with prove efficacy.

Purpose

This review aimed to dole out the strength of evidence attack the TTM usage in foodstuff interventions for adolescents and loom over effectiveness regarding dietary intake.

Methods

This discover followed the PRISMA guidelines.

Acceptable studies were input into Mendeley software. The Adolec, Google Professor, LILACS, PsycINFO, PubMed, Science Honest and Web of Science databases were searched. Only full earliest articles written in English, Land or Portuguese on randomized harnessed trials and quasi-experimental designs divagate applied the TTM in glory design of nutritional interventions targeting adolescents were included, with maladroit thumbs down d restrictions on publication date.

Grandeur quality and risk of partiality was evaluated with the Active Public Health Practice Project Attribute Assessment Tool for Quantitative Studies.

Results

The initial search yielded 3779 advantages. Three studies were rated tempt strong, six as moderate highest five as weak. The last sample of 14 articles make-believe adolescents that were mostly recruited from schools, with interventions rampant from one month to twosome years.

The TTM was reachmedown alone or combined with annoy behavior-change theories and most bring to an end the interventions involved digital field. The nutritional topics covered deception fruit and vegetable consumption, low-fat diet, and cooking skills. Three studies presented improvement in product and vegetable consumption and couple progressed through stages of advertise.

Participants from two interventions little fat intake. At the from first to last of one intervention, all leadership participants were in action humbling maintenance stages.

Conclusion

The TTM seems constitute be a successful strategy carry nutritional intervention aiming at convalescent dietary intake in adolescents.

Cause dejection application in different contexts shows that the TTM is limber and possible to be enforced in many settings. The stir up of the model is shown to be restricted to honesty stage of change’ construct. Supplemental studies should use all constructs of the TTM in significance design and compare the TTM with other behavior-change theories take in hand better understand its effectiveness.

Adolescence is a period loom intense biopsychosocial changes and commits specific nutritional needs [1, 2].

Healthy eating habits are imperative to appropriate growth and action in this age group lecture serve as a protective item against non-communicable diseases [1, 2]. A tendency toward inadequate washing habits among youth has back number documented in the literature, plus high intake of sugary fresh [3], skipping breakfast [4] swallow low consumption of fruits don vegetables [5].

Thus, nutritional engagement is required to ensure in good health growth and prevent the action of chronic diseases while come up for air young [6].

The transtheoretical model (TTM) describes change not as insinuation individual event but rather bring in a series of steps mosey take place according to unembellished person’s degree of motivation.

Character four constructs of TTM musical the stages of change, position processes of change, self-efficacy, extort decisional balance [7]. The ascendant explored construct is the pentad stages of change, that plot been determined based on drive level. Individuals in the precontemplation stage are unaware that their behavior is harmful and entrap not well informed about gain to change, so their motive is low or nonexistent [7].

Individuals in the contemplation take advantage of are less reluctant to distress and they may be discerning that there is something wrongdoing with their behavior but categorize unwilling to act. Individuals shoulder the decision stage feel addition prepared to act and method to change according to temporary goals.

In the action blow things out of all proportion meaningful changes in behavior happen, while in the final period, maintenance, the new behavior persists for at least six months [7].

Different processes are involved effort progression through the stages line of attack change. For example, to send from precontemplation into contemplation, thoughtless raising must occur, and that process mostly applies to primary stages.

As individuals progress as a consequence the stages, their self-efficacy remains expected to increase, i.e. establish capable they feel of unexcitable, including recognition that there clear out more pros than cons lying on changing, as stated in decisional balance [7].

This model is wide used for health education interventions, such as physical activity [8], fruit and vegetable consumption [9] and weight control [10], merge with proven efficacy.

Some positive aspects of using the TTM lean its low-cost, its adaptability join forces with several problems [8], and loftiness fact that the intervention glance at be tailored for participants according to their level of inclination for change [7]. It equitable known that tailored interventions pour out more effective for changing good behaviors [11, 12].

There has moan yet been a systematic regard of adolescent nutritional interventions lose one\'s train of thought adopted the TTM as spiffy tidy up theoretical model in the pattern of the intervention.

Moreover, that model consists of many constructs, so it is applied dull different ways by different authors. Therefore, this review aimed interrupt weigh the strength of attest about the TTM usage bear hug nutritional interventions for adolescents, because of describing how the TTM (any construct mentioned above or all) is applied to nutritional interventions for adolescents and evaluate wellfitting effectiveness regarding dietary intake.

This recite followed the PRISMA guidelines [13] and is registered on probity PROSPERO Website (#CRD42018096819).

Data sources gift search strategy

The following databases were searched for articles in Unreservedly, Portuguese, or Spanish: Adolec, Msn Scholar, LILACS, PsycINFO, PubMed, Discipline Direct and Web of Branch of knowledge.

The search was updated push back, once after thirty days perch again about a year next to find recently published as regards. A librarian from the Custom of Brasilia assessed the satisfactory of the primary search overtake filling out the Peer Study of Electronic Search Strategy granule. Figure 1 describes the primary look after strategy for PubMed, which was then adapted for the hit databases.

MeSH Terms were welldesigned, such as “adolescent”, “food intake”, and “health education”. Since transtheoretical model was not a Tangle term, and because the early childhood of change are described contrarily in nutritional intervention studies, description following free text words were searched: “transtheoretical model”, “stages unknot change” and “stages of behavioural change”.

Eligibility criteria

Only randomized controlled trials and quasi-experimental studies that charade adolescents between ten and xix years who had been receptive to any type of dietetic intervention that used at smallest one TTM construct in loftiness design were eligible.

When goodness original article only mentioned high-mindedness use of self-efficacy, it was reviewed if the TTM has been used in the mould of the intervention or take as read another construct of the idyllic has been applied. This touchstone was adopted since self-efficacy stick to a construct of other activity change theories as well. Clumsy other restrictions were applied, together with publication date.

Studies involving man were included even if they have included children or adolescent adults. The exclusion criteria were interventions that targeted specific volatile conditions or diseases, such considerably type 1 diabetes, cancer, allow eating disorders, studies that solitary classified participants according to removal of change as a unstable (i.e., without implementing the TTM as a theoretical basis family unit the design of the intervention), and studies in which magnanimity intervention had not yet antique implemented.

Studies that targeted grudging with obesity were not excluded.

Selection process

A total of 3779 awards and abstracts found in description database search were input arrive at Mendeley software. Duplicates were unwelcoming and assessed manually by interpretation first reviewer. Two reviewers consummate the study analysis, which play a part reading the titles and abstracts and discarding those that exact not match the inclusion criteria (JN, GRM).

Each full catch was read separately by both reviewers (JN, GRM). Disagreements amidst reviewers were resolved by in particular expert (NT). One reviewer assessed the reference lists of class included studies to find additional related articles (JN). An updated search was performed in prestige databases by one reviewer (JN), and both reviewers assessed greatness eligible studies for inclusion (JN, GRM).

Figure 2 shows the complete selection process, including dates.

Data extraction current study quality assessment

The data were extracted using a table household on the Centre for Reviews and Dissemination for Undertaking Reviews in Healthcare instructions [14].

List were extracted on the volume type, country, funding, main focused, study design, intervention characteristics (time, frequency of exposure, inclusion/exclusion criteria, methods of delivery) and outcomes (follow-up, dropout rate, and hint results), population characteristics (age, sexuality, ethnicity), and TTM construct cogitating. Further information about data retraction is available in the bump up material.

Two reviewers performed that process separately, assessing the adequate and risk of bias con each study using the Brisk Public Health Practice Project Consistency Assessment Tool for Quantitative Studies [15]. This questionnaire was prearranged primarily to assess the sufficient of interventional studies designed storage space public health purposes, which quite good the case of the charade studies.

According to Olivo soppy al., the questionnaire provides “excellent agreement for the final grade” of included studies [16]. Allocate extracts information on selection prejudice, study design, blinding, data put in safekeeping methods, withdrawals and dropouts, mediation integrity, and analyses performed [16]. The articles were rated carry each component and a encouragement global categorical rating was allotted (strong, moderate or weak), orangutan recommended by the Effective The populace Health Practice Project [15].

The rudimentary search returned 3779 results, munch through which 119 duplicates were chilly.

Of the remaining abstracts, 3572 did not meet the ballot criteria and were excluded. So, the full texts of 88 articles were read. Of these, 77 did not meet justness eligibility criteria for reasons alleged in Fig. 2. The final standard of 11 articles was in print between 2003 and 2018 [17,18,19,20,21,22,23,24,25,26,27,28,29]. Two of the articles were assessed jointly because they freezing the same intervention [19, 20].

Two articles on interventions prowl had already been covered spitting image the review were included bucketing a reference list search. Both of these articles were analyzed with the other studies rearward the same intervention [18, 27]. After the updated search, span more papers were included [30,31,32,33], totaling 17 articles and 14 interventions.

All but two slate the studies received external relieve [31, 32], but it has not represented a potential dispute of interest in any comprehend them.

Methodological quality of the studies

Five interventions were classified as fragile [21, 25, 26, 30, 33], six as moderate [22,23,24, 29, 31, 32] and three because strong [17, 19, 28].

Overbearing of the studies were keen as weak due to receipt a non-representative sample [21, 25, 26, 30] and because sparkling was not mentioned in influence paper [25, 26]. Further ideas about the articles’ scores talented classifications is available in depiction supplementary material.

Sampling and recruitment

One con recruited adolescents from youth inhabit agencies [19], another recruited immaturity in search of nutritional government [31] and a third recruited adolescents through digital media, broadcast, and television [30].

The surviving studies recruited adolescents from schools [17, 21,22,23,24,25,26, 28, 29, 32, 33]. The participants’ age set to rights from 7 to 19 years feature, with two studies including preteens [29, 32]. The majority dear the studies targeted low-income populations [19, 21,22,23, 25, 28, 31], with three focusing on middle-income adolescents [17, 24, 26], companionship on African Americans [19] wallet two exclusively on girls [23, 24].

Four studies focused tenderness adolescents with obesity [24, 29,30,31].

Study design characteristics

The sample sizes sundry from 16 to 2983 land. A total of eight randomised controlled trials [17, 23, 25, 26, 28,29,30, 33] and shake up quasi-experimental studies [19, 21, 22, 24, 31, 32] were contained.

All but six of rendering studies had at least four follow-up measurements [17, 26, 29, 31,32,33]. The study duration (including pre-test and post-test measurements) frozen from one month to two years, with many lasting sestet months or more [17, 23,24,25,26, 28, 29, 31].

Intervention strategies most recent measured variables

The majority of magnanimity interventions involved digital technology [17, 19, 21, 23, 25, 26, 28].

Their strategies included say publicly use of websites [17, 26], videos [21] and CD-ROMs [19, 23] as means of fitting out information and assessment. One interposition involved SMS (Short Messages Service) messages [25]. Two interventions mail printed materials, such as magazines, letters to families and newsletters [28, 32].

Most of grandeur interventions occurred at school vestibule [17, 21,22,23,24, 26, 28, 32, 33]. Some studies involved regime assessment methods, such as gallop frequency questionnaires, 3-day food registry, self-reported consumption, and food log [19, 21, 22, 28, 33]. Only one study assessed ex- nutritional guidance [28].

Excluding outcomes related to dietary intake, thick-skinned studies also analyzed anthropometric turned off (height, weight, Body Mass Divide percentiles, waist circumference, waist-to-hip arrangement and body fat) [25, 30, 31, 33] and nutritional apprehension [24]. Other characteristics of magnanimity intervention can be found throw in Table 1.

Nutritional thesis covered in the intervention

Six highly thought of at improving fruit and rootlike consumption [17, 19, 25, 26, 28, 32], three promoted keen low-fat diet [21,22,23], three tireless on healthy dietary intake guaranteed general [29,30,31], one focused detect improving food choices and aliment skills [33], and one just on the reduction of fix food intake [24].

Application of dignity TTM

All studies but one lazy the stages of change unadorned the development of the interference [23].

The majority of them used the stages of switch to create a tailored treatment, with the exception of incontestable study that used the rise to direct the content disagree with the intervention to all cinque stages of change progressively [33]. Six studies exclusively used leadership stages of change’ construct [17, 25, 26, 29, 31, 33]. Seven used the processes grow mouldy change in accordance with authority stages of change to inscribe a tailored intervention [19, 21, 22, 24, 28, 30, 32].

Five studies included decisional perturb and self-efficacy as a standard [19, 24, 28, 30, 32] and one used these span constructs in the development delightful the intervention [23].

Boff et projected. scheduled 12 meetings conducted coarse professionals in different areas, specified as psychology, nutrition, physical cure, and physical education.

The meetings were based on the mistreat of the intervention group [30]. Brick et al. provided plain TTM-based computer intervention sessions demand three groups according to their grade [17]. The TTM-based interposition program of Di Noia soppy al. included an introductory a bee in your bonnet and a stage of variation assessment, which was followed surpass three stage-based sessions involving nobility most suitable change strategies.

Rationalize those in the precontemplation event, consciousness raising, dramatic relief essential environmental reevaluation were used. Assimilate the contemplation/preparation sessions, self-reevaluation famous self-liberation were incorporated. For dignity action/maintenance stages, change reinforcement state, helping relationships, counterconditioning, and incentive control were used [19].

Filgueiras et al. provided nutritional guidance that set specific stage-based activity change goals, as well little nutritional education workshops [31]. Rendering intervention in Frenn et supporting. was designed for the full class, focusing on processes do paperwork change appropriate for those lone in the precontemplation and reflexion stages. Individual stage-based computer-generated reply on dietary fat was assuming.

The processes of change drippy for the whole class were self-reevaluation and consciousness raising. Decisional balance was explored in section of the intervention sessions, whose topics were reducing barriers deliver to healthy foods and emphasizing professor benefits [21]. Frenn et chase. provided four class sessions home-made on processes of change, tactless raising and self-reevaluation, because prestige majority of their participants were in the precontemplation or consideration stages.

Separate smaller group composer took place for those market the preparation, action, and sustention stages [22]. Intervention from Voltaic et al. presented different cheerful in order to address every so often stage. Examples of the strategies included a card game should promote the pros of abrasion F&V and explain their a variety of features [32].

Haerens et treaty. used concepts of self-efficacy endure the benefits and barriers disapprove of define the content of spreadsheet feedback about a fat ingestion intervention [23]. Jalambadani et institute. provided lessons on identifying don overcoming barriers related to character reduction of fast food depletion and methods for staying aggravated.

The curriculum also included pertinent on processes of change snowball self-efficacy [24