Guiding Theories and Principles

Several theories and models of health behavior change and intervention, as well as what we have learned from WATCH, underlie the design and use of the pt-centered physician-delivered intervention, the telephone counseling model, and the GNI to be included. While a complete review of these theories and models is beyond the scope of this application, they are briefly mentioned here. The reader is referred to previous works by the investigators which discuss the theoretical underpinnings of the intervention strategies, with a particular focus on pt-centered counseling. (95-98)  The pt-centered counseling model has its principles built mostly on Social Cognitive Theory (61, 99) with contributions from the Health Belief Model. (100) (see Section B). As with the Stages of Change Model, (101) it emphasizes the importance of understanding the pt’s intentions and confidence relative to change in the target behavior in order to help move him/her forward in the change process. Stages of change theory reflects stages of dietary change – precontemplation, contemplation, ready for action, action, and maintenance. (101, 102) Providers are taught that because change occurs over several stages, they, by their persistent efforts, can be important resources in this process. Their assistance can move the precontemplator to contemplation and the contemplator to action. Physicians and pts need to be aware of and reminded of this process so that neither become discouraged or alienated from each other.

Important components of social cognitive theory reflected in pt-centered counseling include: the need for active participation by the pt in developing a plan for change, the importance of a positive self-efficacy (or confidence) to effect a specific change, and attention to the environment. (99, 103, 104) Pt-centered counseling emphasizes the use of past experiences of change to help the pt develop motivation and a positive self-efficacy.

The Relapse Prevention Model, (54, 105) in addition to social cognitive theory, figures prominently in the telephone counseling intervention.  Relapse prevention training stresses the need to recognize cues and characteristics of high-risk situations (assessment skills) and to develop specific skills (e.g., communication, initiation of support, stress management) so as to mobilize a coping response to promote dietary change.

Treatment Conditions

Control (Condition I):  This condition includes physician-delivered nutrition intervention training plus the office support program, in addition to the availability of the Group Nutrition Intervention (GNI) program.

Intervention Condition  (Condition II): includes the interventions in Condition I plus the Systems-Based Lipid Management Program (SBLMP), telephone counseling and other support materials. (Intervention Summary: Figure 1)