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Cognitive approach to nutrition in a patient centered approach: implementing tailored nutrition advice for oncology patients
Abstract
This theoretical overview stresses the importance of a personalized approach to the study of the relationship between nutrition and prevention by the use of a cognitive approach. An adequate nutrition program should play a fundamental aspect of patient-centered care, but also is the best prevention strategy in disease-free subjects. We argue that an integrated methodology, based on a patient-centered and tailored approach, must assess all the factors involved within individual food choices in order to recognize values, beliefs and needs related to food intake, both in cancer patients and in disease-free patients. An integrated approach is advocated, since the tailoring process requires both biological and psychological data in order to appraise the individual’s needs and promote adequate action plans. This process of integrating information delivered from different sources is what we call a “cognitive approach” to nutrition.
... Consequently, an increasing amount of information included genetic features and patients' preferences, are needed to find the best solution in a given situation. In this framework, a patient-centred model should be adopted [11, 12] (Mazor et al 2012; Lucchiari, Masiero, Pravettoni, 2013). However, little research is now available in this domain and most physicians, at least in Italian hospitals are advised to use a more directive paternalistic approach in this context. ...
During the last 20 years, numerous studies have highlighted the need to consider Quality of Life (QoL) issues in the treatment of brain cancer. However, gaps in scientific knowledge are still present as we have poor data surrounding the whole experience in patients and regarding their needs. The present study was aimed at evaluating QoL in brain cancer patients and correlated aspects. In particular, we aimed to assess QoL, mood state, and emotional issues in order to describe the patients’ experience to find out the critical aspects involved.
Methods: We obtained data from 85 patients during chemotherapy treatment at the National Neurological Institute ‘C. Besta’ of Milan, Italy. We used standardised questionnaires to assess different aspects of patients’ QoL. In particular, the functional assessment of cancer therapy-brain (FACT-Br) and the Hamilton scale were used. We also performed a semi-structured ad hoc interview in order to collect narrative data about patients’ experience.
Results: Our data depict a difficult adjustment process to the illness, even though positive elements emerged. Indeed, patients reported a satisfying self-perceived QoL, although specific concerns are still present. Further, even if many patients report depressive symptoms, only a minority have a severe condition.
Conclusion: Brain cancer may heavily affect patients’ QoL and well being. However, some element of the context may improve the adjustment to the disease. In particular, we found that most patients found psychosocial resources to cope with cancer and that spiritual well being also seems to play a key role. These issues deserve further studies in order to obtain significant clinical recommendations.
The present overview focuses on evidence of smoking cessation approaches in oncology settings with the aim to provide health personnel a critical perspective on how to help their patients. This narrative review is structured in two main sections: the first one describes the psycho-cognitive variables involved in the decision to continue smoking after a cancer diagnosis and during the treatment; the second section relates methods and tools may be recommended, being evidence-based, to support smoking cessation in oncology settings. Active smoking increases not only susceptibility to common cancers in the general population, but also increases disease severity and comorbidities in cancer patients. Nowadays, scientific evidence has identified many strategies to give up smoking, but a lack of knowledge exists for treatment of nicotine dependence in the cancer population. Health personnel is often ambiguous when approaching the problem, while their contribution is essential in guiding patients towards healthier choices. We argue that smoking treatments for cancer patients deserve more attention and that clinical features, individual characteristics and needs of the patient should be assessed in order to increase the attempts success rate. Health personnel that daily work and interact with cancer patients and their caregivers have a fundamental role in the promotion of the health changing. For this reason, it is important that they have adequate knowledge and resources in order to support cancer patients to stop tobacco cigarette smoking and promoting and healthier lifestyle.
Past behavior guides future responses through 2 processes. Well-practiced behaviors in constant contexts recur because the processing that initiates and controls their performance becomes automatic. Frequency of past behavior then reflects habit strength and has a direct effect on future performance. Alternately, when behaviors are not well learned or when they are performed in unstable or difficult contexts, conscious decision making is likely to be necessary to initiate and carry out the behavior. Under these conditions, past behavior (along with attitudes and subjective norms) may contribute to intentions, and behavior is guided by intentions. These relations between past behavior and future behavior are substantiated in a meta-analytic synthesis of prior research on behavior prediction and in a primary research investigation.
Diet and genomes interact. Nutrition has the most important life-long environmental impact on human health. While nutrigenetics addresses how an individual's genetic makeup predisposes for dietary susceptibility, nutrigenomics asks how nutrition influences the expression of the genome. Nutrigenomics builds on the three omics disciplines transcriptomics, proteomics and metabolomics. They are a prerequisite for nutritional systems biology, the understanding of the interaction between food components and diet with cells, organs and the whole body. Personalized nutrition is a conceptual analog to personalized medicine. While there are food products available that address requirements or preferences of specific consumer groups, these products are based on empirical consumer science rather than on nutrigenomics and nutrigenetics. The latter two build the science foundation for understanding human variability in preferences, requirements and responses to diet, and may become the future tools for consumer assessment motivated by personalized nutritional counseling for health maintenance and disease prevention.
In the present medical context, the evaluation and the monitoring of factors other than mere physical symptoms are an urgent demand. In particular, the issue of quality of life (QoL) has become a relevant target in the treatment of cancer. However, the approach towards these aspects is not well standardized and the actual applications in a concrete setting are fragmented, left to personal or local initiative. If this is true for QoL in general, it is particularly relevant in the specific field of nutrition. Indeed, though the growing awareness of a correlation between chronic diseases and dietary habits has led to an increased interest in nutrition, both before and after cancer, very little is still known about the methods that measure this important variable of the QoL. Indeed, good nutrition may have a relevant impact on QoL, positively affecting both the physical and psychological well-being. Targeting this issue implies using proper instruments to both monitor and educate the patients. Hence, we argue that it is vital for oncologists to be able to individuate the best tool available in a specified context, so as to achieve an important goal with little effort, also adopting standardized strategies proved to be efficacious. In this framework, we briefly reviewed the tools more frequently reported in the scientific literature. We suggest that through a cognitive approach, it is possible to achieve important clinical targets, initially by understanding the patients' needs, values, and psychosocial factors involved in nutritional behaviour and food-related decisions, in order to develop a personalized approach. Hence, this is the only way to support concrete actions for promoting healthier diets, thus preventing recurrences, monitoring chronic conditions, and supporting a good QoL.
Obesity is a major public health challenge with over 65% of US adults either overweight or obese. Estimated annual costs of
obesity are $78.5 billion. Self-monitoring is a critical skill for successful weight management. However, self-monitoring
is labor-intensive, and compliance is often difficult. In this paper, the authors describe the Patient-Centered Assessment
and Counseling Mobile Energy Balance (PmEB) mobile phone application that allows users to self-monitor caloric balance in
real time. The application was developed and applied in a four-phase iterative research and development methodology. A usability
study and a preliminary feasibility study were conducted. The 1month feasibility study measured compliance and satisfaction
among a sample of 15 participants randomized to one of three groups: (1) a paper diary group, (2) a PmEB group with one daily
prompt, and (3) a PmEB group with three daily prompts. PmEB scored highly on usability, compliance, and satisfaction. In addition,
mobile phone group users scored PmEB the same as or better than Paper Group members scored the paper diary in nearly all categories.
Thematic analysis of comments revealed very positive reviews of PmEB as well as areas for improvement. PmEB is both usable
and feasible for weight management self-monitoring, and the iterative pilot study methodology was effective in improving its
usability.
A system approach termed P4 medicine has recently been proposed in the field of oncology. This approach has been advanced as an extension of what is usually called 'personalized' or 'genomic medicine'. P4 medicine creates effective predictive, personalized, preventive and participatory models to treat patients. In order to give more relevance to the behavioural component that impinges on the way individuals act to prevent, cope and react to illnesses, how they decide between different therapeutic options and interact with physicians and adhere to treatment, we propose that P4 medicine should be transformed into P5 medicine. The fifth P represents the psycho-cognitive aspects to be considered in order to empower the patient, increase his/her quality of life and transform him/her from a passive recipient into an active decision-maker in the treatment process.
The phrase "patient-centered care" is in vogue, but its meaning is poorly understood. This article describes patient-centered care, why it matters, and how policy makers can advance it in practice. Ultimately, patient-centered care is determined by the quality of interactions between patients and clinicians. The evidence shows that patient-centered care improves disease outcomes and quality of life, and that it is critical to addressing racial, ethnic, and socioeconomic disparities in health care and health outcomes. Policy makers need to look beyond such areas as health information technology to shape a coordinated and focused national policy in support of patient-centered care. This policy should help health professionals acquire and maintain skills related to patient-centered care, and it should encourage organizations to cultivate a culture of patient-centeredness.
This article reports the development and evaluation of a computer game (RightWay Café) as a special medium to promote a healthy diet for young adults. Structural features of computer games, such as interactive tailoring, role playing, the element of fun, and narrative, were operationalized in the RightWay Café game to afford behavior rehearsal in a safe and entertaining way. Theories such as the health belief model, social cognitive theory, and theory of reasoned action guided the content design of the game to influence mediators of behavior change, including self-efficacy, perceived benefits, perceived barriers, and behavior change intention. A randomized controlled evaluation study with pretest, posttest, and follow-up design demonstrated that this game was effective in teaching nutrition and weight management knowledge and increasing people's self-efficacy and perceived benefits of healthy eating, as well as their intention to be on a healthy diet. Limited long-term effects were also found: participants in the game-playing group had greater self-efficacy than participants in the control group after 1 month. This study validates the computer game-based approach to health promotion for young adults. Limitations and implications are also discussed.
To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease.
Cluster randomised controlled trial.
883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity.
Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity.
Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months.
Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months. No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation.
Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge.
To examine stage-matched nutrition counseling by family physicians and its effect on dietary intake, anthropometry, and serum lipid levels in patients at elevated risk for cardiovascular disease.
In this controlled trial, patients randomized to intervention practices received nutrition information following the Stages-of-Change Model, and patients randomized to control practices received usual care.
At both 6 and 12 months after baseline, total fat intake and saturated fat intake declined significantly more in the intervention group than in the control group: -5.7% and -2.6% of energy, respectively, at 6 months, and -3.6% and -1.7% of energy, respectively, at 12 months. For energy intake, body weight, and BMI, there were significant differences between groups only at 6 months: -0.8 megajoules (MJ), -0.7 kg, and -0.3 kg/m(2), respectively. None of the serum lipid values changed significantly between groups at 12 months.
Nutritional counseling based on stages of change led to reductions in dietary fat intake and weight loss in the short term. However, we found no corresponding changes in serum lipid concentrations.
A field experiment investigated the prediction and change in repeated behaviour in the domain of travel mode choices. Car use during seven days was predicted from habit strength (measured by self-reported frequency of past behaviour, as well as by a more covert measure based on personal scripts incorporating the behaviour), and antecedents of behaviour as conceptualized in the theory of planned behaviour (attitude, subjective norm, perceived behavioural control and behavioural intention). Both habit measures predicted behaviour in addition to intention and perceived control. Significant habit x intention interactions indicated that intentions were only significantly related to behaviour when habit was weak, whereas no intention-behaviour relation existed when habit was strong. During the seven-day registration of behaviour, half of the respondents were asked to think about the circumstances under which the behaviour was executed. Compared to control participants, the behaviour of experimental participants was more strongly related to their previously expressed intentions. However, the habit-behaviour relation was unaffected. The results demonstrate that, although external incentives may increase the enactment of intentions, habits set boundary conditions for the applicability of the theory of planned behaviour.
Emerging Health Information Technologies (HIT) such as Electronic Health Record (EHR) and PHR systems and Heath Information Exchanges (HIEs) facilitate access to and sharing of patients' medical data distributed in different HIT systems. One of the many ...
This paper summarizes research on determinants of repeated behaviors, and the deci- sion processes underlying them. The present research focuses on travel mode choices as an example ofsuch behaviors. It is proposed that when behavior is performed repeatedly and becomes habitual, it is guided by automated cognitive processes, rather than being preceded by elaborate decision processes (i.e,, a decision based on attitudes and inten- tions). First, current attitude-behavior models are discussed, and the role of habit in these models is examined. Second, research is presented on the decision processes pre- ceding travel mode choices. Based on the present theoretical and empirical overview, it is concluded that frequently performed behavior is often a matter of habit, thereby es- tablishing a boundary condition for the applicability of attitude-behavior models. How- ever, more systematic research is required to disentangle the role of habit in attitude-behavior models and to learn more about the cognitive processes underlying habitual behavior.
Undergraduates at an American university were asked questions about their attitudes, subjective norms, habits, and intentions towards using a condom during sexual intercourse. Consistent with previous research (Chan and Fishbein, 1993; Trafimow, 1994), intentions were well predicted by attitudes and subjective norms (r = 0.88 and r = 0.73, p < 0.01 in both cases). Intentions were also well predicted by habits (r = 0.77, p < 0.01). More interestingly, however, for participants who were in the habit of using condoms, attitudes and subjective norms were not significant predictors of intentions to use condoms in the future (r = 0.18 and r = 0.10, p
Background This pilot study aimed to explore the nutritional knowledge, attitudes and dietary fat consumption in male students attending Leeds Metropolitan University.Methods A Food Frequency Questionnaire (FFQ) was used to determine the fat intakes of subjects. This was incorporated into a questionnaire designed to measure nutritional knowledge and attitudes. Questions were also asked about the subject characteristics, such as weight, height and alcohol consumption.Results Eighty subjects were approached, from whom 56 questionnaires were returned completed. The results revealed few significant differences between subject characteristics according to fat intakes, with the exception of alcohol consumption, which was greater in the high fat consumers. The main findings of the study were that subjects with a high fat intake had significantly more negative attitudes towards reducing fat consumption compared with those who had a lower fat intake. However, there was no statistically significant difference between nutritional knowledge and fat consumption and no relationship was found between level of nutritional knowledge and attitudes.Conclusion It was concluded that negative attitudes towards reducing fat consumption might be more important barriers to dietary change than level of nutritional knowledge in male students. This constitutes an important target for health promoters in encouraging dietary change in men.
This study focuses on the role of habit in the process of information use underlying daily travel mode choices. Based on the ‘policy capturing’ paradigm, eighty-two students performed a multiattribute travel mode judgment task, in which they could use information about travel circumstances in order to make a number of judgments. Measures of information use were obtained by performing multiple regression analyses for each subject. It was found that habit reduced the elaborateness of information use in judgments of travel mode use. This effect was independent of effects of manipulated accountability demands.
The last decade has witnessed a steady embrace of genomic and personalized medicine by senior government officials, industry leadership, health care providers, and the public. Genomic medicine, which is the use of information from genomes and their derivatives (RNA, proteins, and metabolites) to guide medical decision making-is a key component of personalized medicine, which is a rapidly advancing field of health care that is informed by each person's unique clinical, genetic, genomic, and environmental information. As medicine begins to embrace genomic tools that enable more precise prediction and treatment disease, which include "whole genome" interrogation of sequence variation, transcription, proteins, and metabolites, the fundamentals of genomic and personalized medicine will require the development, standardization, and integration of several important tools into health systems and clinical workflows. These tools include health risk assessment, family health history, and clinical decision support for complex risk and predictive information. Together with genomic information, these tools will enable a paradigm shift to a comprehensive approach that will identify individual risks and guide clinical management and decision making, all of which form the basis for a more informed and effective approach to patient care. DNA-based risk assessment for common complex disease, molecular signatures for cancer diagnosis and prognosis, and genome-guided therapy and dose selection are just among the few important examples for which genome information has already enabled personalized health care along the continuum from health to disease. In addition, information from individual genomes, which is a fast-moving area of technological development, is spawning a social and information revolution among consumers that will undoubtedly affect health care decision making. Although these and other scientific findings are making their way from the genome to the clinic, the full application of genomic and personalized medicine in health care will require dramatic changes in regulatory and reimbursement policies as well as legislative protections for privacy for system-wide adoption. Thus, there are challenges from both a scientific and a policy perspective to personalized health care; however, they will be confronted and solved with the certainty that the science behind genomic medicine is sound and the practice of medicine that it informs is evidence based.
The leading causes of death in the United States are predominantly attributable to modifiable behaviors. Patients with behavioral risk factors for premature death and disability, including dietary practices; sexual practices; level of physical activity; motor vehi cle use patterns; and tobacco, alcohol, and illicit sub stance use, are seen far more consistently by primary care providers than by mental health specialists. Yet models of behavior modification are reported, debated, and revised almost exclusively in the psychology literature. While the Stages of Change Model, or Transtheo retical Model, has won application in a broadening array of clinical settings, its application in the primary care setting is apparently quite limited despite evidence of its utility [Prochaska J, Velicer W. Am J Health Promot 1997;12:38-48]. The lack of a rigorous behavioral model developed for application in the primary care setting is an impediment to the accomplishment of public health goals specified in the Healthy People objectives and in the reports of the U.S. Preventive Services Task Force. The Pressure System Model reported here synthesizes elements of established behavior modification theories for specific application under the constraints of the primary care setting. Use of the model in both clinical and research settings, with outcome evaluation, is encouraged as part of an effort to advance public health.
FRESH START is a randomized controlled trial that will test whether a personally tailored, distance-medicine-based program will increase exercise and fruit and vegetable consumption, and decrease fat intake of individuals recently diagnosed with breast or prostate cancer.
Early-stage breast and prostate cancer cases (N= 530) will be identified within 9 months of diagnosis from hospital cancer registries and large oncologic practices throughout the United States. These individuals will be sent a letter of invitation and screened for eligibility. After a baseline telephone interview, participants will be randomized into one of two arms that receive materials aimed at increasing exercise and fruit and vegetable intake, and decreasing dietary fat: 1). an experimental arm that receives a workbook and a series of six 4-page newsletters delivered every 7 wk and personally tailored on type of cancer, cancer coping style, race, age, self-efficacy, stage of readiness, and barriers and/or progress toward goal behavior (i.e., >or= 30 min of exercise at least 5 d.wk, >or= 5 servings of vegetables and fruit per day, and <or= 30% of calories from fat); or 2). a control arm that receives a series of nontailored health brochures. Follow-up interviews scheduled 1 and 2 yr postbaseline will determine short- and long-term efficacy and the effects of the interventions on other endpoints (quality of life, perceived health, etc.). Factors, such as gender, race, and social support, also will be explored to determine potential interactions with program efficacy.
Given the growing number of cancer survivors, distance-medicine-based interventions addressing multiple behaviors and targeting this high-risk group have the potential to make a positive and broad public health impact.
Patients seeking genetic testing for inherited breast cancer risk are typically educated by genetic counselors; however, the growing demand for cancer genetic testing will likely exceed the availability of counselors trained in this area. We compared the effectiveness of counseling alone versus counseling preceded by use of a computer-based decision aid among women referred to genetic counseling for a family or personal history of breast cancer.
We developed and evaluated an interactive computer program that educates women about breast cancer, heredity, and genetic testing. Between May 2000 and September 2002, women at six study sites were randomized into either: Counselor Group (n = 105), who received standard genetic counseling, or Computer Group (n = 106), who used the interactive computer program before counseling. Clients and counselors both evaluated the effectiveness of counseling sessions, and counselors completed additional measures for the Computer Group. Counselors also recorded the duration of each session.
Baseline characteristics did not differ significantly between groups. Participants and counselors both rated the counseling sessions as highly effective, whether or not the sessions were preceded by computer use. Computer use resulted in significantly shorter counseling sessions among women at low risk for carrying BRCA1/2 mutations. In approximately half of the sessions preceded by clients' computer use, counselors indicated that clients' use of the computer program affected the way they used the time, shifting the focus away from basic education toward personal risk and decision-making.
This study shows that the interactive computer program "Breast Cancer Risk and Genetic Testing" is a valuable adjunct to genetic counseling. Its use before counseling can shorten counseling sessions and allow counselors to focus more on the clients' individual risks and specific psychological concerns. As the demand for counseling services increases, a program such as this can play a valuable role in enhancing counseling efficiency.
Cancer survivors are a growing population in the United States because of earlier cancer diagnosis, the aging of society, and more effective risk reduction and treatment. Concerns about the long-term physical, psychosocial, and economic effects of cancer treatment on cancer survivors and their families are increasingly being recognized and addressed by public, private, and non-profit organizations. The purpose of this paper is to discuss how survivorship fits within the framework of comprehensive cancer control. We summarize three national reports on cancer survivorship and highlight how various organizations and programs are striving to address the needs of cancer survivors through public health planning, including the challenges these groups face and the gaps in knowledge and available services. As cancer survivorship issues are being recognized, many organizations have objectives and programs to address concerns of those diagnosed with cancer. However, better coordination and dissemination may decrease overlap and increase the reach of efforts and there is limited evidence for the effectiveness and impact of these efforts.
Improving diet and exercise can reduce survivors' risk of cancer-related fatigue, poor physical functioning, and potential recurrence. A cancer diagnosis can represent a 'teachable moment', leading survivors to make positive changes in diet and exercise behaviors; however, little is known about how often this occurs or about factors that enhance or limit survivors' ability to make these changes. This cross-sectional descriptive study investigated both the prevalence and clustering of self-reported changes in diet and exercise and how these changes related to ongoing cancer-related symptoms, social support, and stressful life events among long-term breast cancer survivors.
Survivors (n=227, response rate=72%) of a prior Cancer and Leukemia Group B treatment trial, on average 12 years post-diagnosis, completed a mailed survey assessing health behavior changes since diagnosis and current symptoms, social support, and stressful life events.
Over half of survivors reported making positive exercise or diet changes since diagnosis: over 25% reported making exercise and diet changes. Analyses of covariance models showed that survivors who reported increasing their exercise also reported lower fatigue. Trends were also found between increased fruit and vegetable intake and decreased fatigue and between increased exercise and increased social support.
These results underscore the need for health promotion efforts among survivors. Exercise promotion is especially needed since more survivors attempted to change dietary behaviors than exercise on their own. Further, fatigue may limit survivors' ability to change their health behaviors; alternatively, survivors who increase their exercise may experience less fatigue.
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