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The process of lipid-lowering dietary change as experienced by hyperlipidemic adults Potyok, Alysone Louise 1997

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THE PROCESS OF LIPID-LOWERING DIETARY CHANGE AS EXPERIENCED BY HYPERLIPLDEMIC ADULTS by ALYSONE LOUISE POTYOK B.Sc, Queen's University, 1992 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR T H E D E G R E E OF MASTER OF SCIENCE in T H E F A C U L T Y OF GRADUATE STUDIES (The School of Family and Nutritional Sciences) We accept this thesis as conforming to the required standard T H E UNIVERSITY OF BRITISH COLUMBIA October 1997 © Alysone Louise Potyok, 1997 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library, shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall hot be allowed without my written permission. Department of VVov^Aq T \ t\\. oWi V\QvV The University of British Columbia Vancouver, Canada Date g ) c J t to: J W . DE-6 (2788) ABSTRACT Die t modi f icat ion is the principal therapy endorsed fo r reducing elevated b lood l ip id levels; however, efforts p romot ing "compl iance" are often unsuccessful. This study used a construct iv ist paradigm and grounded theory methodology to explore the process o f l ip id -lower ing dietary change. Fourteen hyperl ipidemic adults were recrui ted from a hospital-based outpat ient l ip id cl inic program in Vancouver, Br i t i sh Columbia. A l l informants had h igh b lood l ip id levels, were free o f signs o f heart disease, and were in the action stage o f dietary change (i.e., they were actively modi fy ing one or more o f their eating behaviours). The informants were interv iewed at least tw ice to learn about their experiences w i t h l ip id- lower ing dietary change and generate a theoretical f ramework o f the change process. I n depth face-to-face interviews and telephone interviews generated a rich qualitative data base o n the process o f dietary change as experienced by hyperl ipidemic adults. Mu l t i p l e stages o f simultaneous data col lect ion, analysis and interpretat ion produced a theoretical f ramework and conceptual model describing the process o f dietary change. A conceptual model was developed t o explain h o w the informants experienced the process o f dietary change. Be ing mot ivated, f inding personal meaning fo r change, mak ing a personal commitment to change and various personal characteristics were impor tant dr iv ing factors in terms o f ini t iat ing and maintaining the change process. M a k i n g changes invo lved experiment ing and making compromises in order to f ind a personally acceptable balance between enjoying l i fe and making enough changes to achieve desirable outcomes. Cycles o f sl ipping and get t ing back on t rack were also part o f the process. Factors w h i c h helped or interfered w i t h making changes and some corresponding coping strategies were also i i identi f ied. The findings o f this study showed that dietary change is not about adhering to the prescript ions o f others, but about making one's o w n decisions about what is best fo r oneself. B y considering the decision making role o f individuals undergoing change, nu t r i t ion educators can help clients make reasoned decisions about health-related behaviours. i i i T A B L E O F C O N T E N T S A B S T R A C T ii T A B L E O F C O N T E N T S iv L I S T O F T A B L E S vii i L I S T O F F I G U R E S , ix A C K N O W L E D G M E N T S x C H A P T E R 1: I N T R O D U C T I O N 1 C H A P T E R 2: B A C K G R O U N D A N D L I T E R A T U R E R E V I E W 5 2 . 1 . CORONARY HEART DISEASE, BLOOD CHOLESTEROL A N D DIET 5 2.1.1. Coronary Heart Disease Risk Factors 7 2.1.2. Lipid-Lowering Dietary Modification 9 2.1 .2 .1 . Cholesterol L o w e r i n g Dietary Factors 12 2.1.2.2. Tr ig lycer ide L o w e r i n g Dietary Factors 17 2.1.3. Expected Magnitude of Cholesterol Reduction 77 2.1 .3 .1 . Var iable Responses to Dietary Mod i f i ca t ion 19 2.1.3.2. The Effectiveness o f Dietary Therapy 21 2.2. HEALTH BEHAVIOUR THEORIES 24 2.3. LIMITATIONS OF TRADITIONAL THEORIES A N D MODELS 33 2.4. FACTORS INFLUENCING DIETARY CHANGE 36 2.4.1. The Determinants of Dietary Behaviour 38 2.4.2. Promoting Dietary Change 40 2.4 .2 .1 . M o t i v a t i o n or Readiness Fo r Change 41 2.4.2.2. Faci l i tators and Barriers o f Dietary Change .45 2.4.2.3. Compl iance Issues and Dietary Change 47 2.4.2.4. Relapse Prevent ion Strategies 52 2.4.2.5. N e w Direct ions fo r Dietary Change Research 53 2.4.3. Understanding the Process of the Dietary Change 55 2.5. SUMMARY .-........... ; 60 C H A P T E R 3: D E S I G N A N D M E T H O D S 62 i v 3 . 1 . R E S E A R C H O B J E C T I V E S 6 2 3 . 2 . A C O N S T R U C T I V I S T P A R A D I G M 6 2 3 . 3 . R E S E A R C H S T R A T E G Y 6 5 3.3. 1. Qualitative Methods 66 3.3.2. Grounded Theory 67 3 .4 . R E S E A R C H P R O C E D U R E S 7 0 3.4.1. Sample Selection 70 3.4.2. Informant Recruitment. 72 3.4.3. Data Collection 73 3.4.4. Data Analysis 77 3 . 4 . 4 . 1 . Open Coding and Data Interpretation 7 7 3 . 4 . 4 . 2 . Developing A Model and Theoretical Framework 8 0 3 . 5 . CRITERIA F O R A S S E S S I N G RESEARCH QUALITY 8 3 3.5.1. Establishing Trustworthiness 84 3 . 5 . 1 . 1 . Credibility 8 4 3 . 5 . 1 . 2 . Transferability; 8 5 3 . 5 . 1 . 3 . Dependability 8 6 3 . 5 . 1 . 4 . Confirmability 8 6 3.5.2. Theoretical Sensitivity 88 3.5.3. Usefulness of Findings 89 C H A P T E R 4 : RESULTS 91 4 . 1 . S T U D Y I N F O R M A N T S 9 1 4 . 2 . C H A R A C T E R I S T I C S O F H A V I N G H I G H B L O O D L I P I D L E V E L S 9 4 4 . 3 . H E A L T H Y E A T I N G 9 6 4.3.1. Defining Healthy Eating 96 4 . 3 . 1 . 1 . Food Appropriateness 9 7 Appropriate and Inappropriate Food Components 9 9 Appropriate and Inappropriate Foods 1 0 2 4 . 3 . 1 . 2 . Knowing What To Eat 1 0 4 4.3.2. Establishing Healthy Eating Behaviours 107 4 . 3 . 2 . 1 . At Home 1 0 7 Eating Less 1 0 7 Eating More 1 1 2 Substituting Foods 1 1 2 Altering The Method of Preparation 1 1 2 v 4.3.2.2. A w a y F r o m H o m e 113 Order ing Careful ly 113 Eat ing Selectively 116 M a k i n g the Best o f I t 119 L im i t i ng The Frequency O f The Event 120 4.4. T H E PROCESS OF M A K I N G DIETARY CHANGES 121 4.4.1. Driving Factors......... 123 4.4 .1 .1 . Becoming Mot i va ted 123 Be ing Concerned 123 Finding Personal Meaning 130 Perceived Ab i l i t y T o M a k e Changes 131 Establishing a "Posi t ive" A t t i tude 134 Past Outcomes 134 4.4.1.2. Resolv ing T o M a k e Changes 137 4.4.1.3. Personal Circumstances 138 4.4.2. Cycles of Making Changes 143 4A.2.1. F ind ing A Balance 144 En joy ing L i f e 146 M a k i n g Enough Changes.. 148 Compromis ing 151 4.4.2.2. Cycles o f Sl ipping and Gett ing Back on Track 153 4.4.2.3. Evaluat ing Outcomes and Ef for ts and M a k i n g Decisions 157 4.4.3. Intervening Factors 159 4 .4 .3 .1 . Get t ing Feedback 163 4.4.3.2. Ab i l i t y t o Devise Coping Strategies 164 Keep ing The Die t Interesting 166 Cont ro l l ing Food Avai labi l i ty 166 N o t Deny ing Self. 167 N o t M a k i n g Except ions 169 Incorporat ing N e w Behaviours 170 4.4.4. Summary 171 C H A P T E R 5: D I S C U S S I O N 173 5 .1 . HEALTHY EATING 173 5.2. A THEORETICAL FRAMEWORK OF T H E DIETARY CHANGE PROCESS 176 5.2.1. Variable Responsiveness To Dietary Modifications 178 5.2.2. The Role of Concepts From Health Behaviour Theories 179 5.2.3. Driving Factors 182 5.2.4. Making Decisions To Find A Balance Instead of "Complying" 184 v i 5.2.5. Helpers and Barriers to Dietary Change . 186 5.2.6. Devised Coping Strategies 188 5 . 2 . 6 . 1 . The Importance o f Get t ing Feedback 1 8 9 5 . 2 . 6 . 2 . A l l o w i n g Treats Versus Slipping or Relapsing 1 9 0 5 . 2 . 6 . 3 . Incorporat ing Changes In to a Li festyle 1 9 0 5 . 3 . S U M M A R Y O F I N S I G H T S 191 5 .4 . LDvuTATIONS O F THE RESEARCH 1 9 3 5 .5 . I M P L I C A T I O N S F O R R E S E A R C H 1 9 5 5 .6 . I M P L I C A T I O N S F O R P R A C T I C E 1 9 8 REFERENCES 203 APPENDICES... 215 A P P E N D I X A : R E C R U I T M E N T N O T I C E 2 1 5 A P P E N D I X B : S C R E E N I N G Q U E S T I O N N A I R E 2 1 6 A P P E N D I X C: C O N S E N T F O R M 2 1 7 A P P E N D I X D : E T H I C S C O M M I T T E E C E R T I F I C A T E S O F A P P R O V A L 2 1 8 A P P E N D I X E : P R E L I M I N A R Y I N T E R V I E W G U I D E 2 2 0 A P P E N D I X F: L A T E R I N T E R V I E W G U I D E 2 2 1 A P P E N D I X G: I N F O R M A N T M A T L O U T 2 2 3 A P P E N D I X H : D E M O G R A P H I C Q U E S T I O N N A I R E 2 2 9 A P P E N D L X I : I N F O R M A N T S ' O U T L O O K S R E G A R D I N G D I A G N O S I S 2 3 0 vii LIST OF TABLES Table 2.1 Die tary Therapy o f H i g h B l o o d Cholesterol 14 Table 4.1 Demographic Profi les o f Informants 92 Table 4.2 L i p i d Characteristics o f Informants 93 Table 4.3 C o m m o n Foods Informants T r y T o Eat Less O f 103 Table 4.4 C o m m o n Foods Informants T r y T o Eat M o r e Of. 103 Table 4.5 Intervening Factors W h i c h A c t A s Helpers 161 Table 4.6 Intervening Factors W h i c h A c t A s Barriers 162 Table 4.7 Devised Cop ing Strategies 165 v i i i LIST OF FIGURES Figure 2.1 Total and HDL-Cholesterol Classification of Adults Without Evidence of CHD ..10 Figure 2.2 LDL-Cholesterol Classification of Adults Without Evidence of CHD 11 Figure 2.3 Shannon's (1990) Conceptual Model to Guide Nutrition Education Research 38 Figure 4.1 Establishing Healthy Eating Behaviours 108 Figure 4.2 A Conceptual Model of the Process of Making Dietary Changes 122 ACKNOWLEDGMENTS I would like to gratefully acknowledge the assistance of the following people for helping with one of the most challenging endeavours I have accomplished to date. First, I would like to thank my husband Warren Martel for his love and continued support. He had the wisdom to know when I should be left alone to work and when I needed to take breaks to relax. His sacrifices and encouragement compelled me to persevere at those times when I thought I could not continue. Next, I would like to give many thanks to my thesis supervisor, Gwen Chapman for introducing me to the realm of qualitative research, for giving me the freedom the explore my own interests, and for always having the time to meet with me. Her guidance and insights throughout the project were invaluable. I would also like to thank the members of my thesis committee, Joy Johnson, Sue Crawford, and Susan Barr, who provided thoughtful guidance and criticism throughout this project. I would especially like to thank them for their input during the later stages of developing the theoretical framework and constructing the conceptual model. I also wish to thank the dietitians at the Lipid Clinic, Frances Johnson, Shauna Ratner and Kay McQueen, for helping me with informant recruitment. Thanks also to my good friend Jenn Arntorp for taking time from her busy schedule to help me enter the graphics into the computer. Finally, I would like to thank the informants of this study for giving me their time and sharing their experiences with me. I N T R O D U C T I O N C H A P T E R 1: INTRODUCTION There has been a dramatic increase in public, private and professional interest i n prevent ing disabil i ty and premature death through changes in indiv idual health behaviours. M c L e r o y and colleagues (1988) assert that much o f this interest in health p r o m o t i o n and disease prevent ion was stimulated by: a) epidemiologic t ransi t ion f r o m infect ious t o chronic diseases as leading causes o f death, b) aging o f the populat ion, c) rapidly elevating health care costs, and d) epidemiologic data l ink ing individual behaviours to increased r isk o f morb id i ty and morta l i ty . The failure o f continued expenditures on health care to reduce mor ta l i ty from chronic diseases has also prompted interest in disease prevent ion (A l l ison, 1991). This shift in concern from treatment t o prevention is exempli f ied by Canada's nu t r i t ion recommendations. Wh i le earlier recommendations were developed to prevent nut r i t ion deficiency, those o f the last twenty years have increasingly focused on reducing the r isk o f chronic diseases. Indeed, the latest recommendations by Heal th and Wel fare Canada (1990) deal w i t h "d ietary patterns that w i l l provide nutrients in recommended amounts whi le min imiz ing the r isk o f chronic disease" (p. 11). Overal l , i t is increasingly being recognized that "heal thy nut r i t ion plays an important role in health maintenance and the reduct ion o f r isk fo r chronic disease" (Glanz and Mul l i s , 1988, p.395). These recommendations come at a t ime when coronary heart disease ( C H D ) continues to be the leading cause o f death in Canada. Whi le populat ion studies indicate an increased r isk fo r C H D w i t h increasing levels o f b lood cholesterol, clinical trials show a decline i n this r isk w i t h decreasing b lood cholesterol levels. The principle therapy endorsed fo r hypercholesterolemic individuals is diet modif icat ion, w i t h an emphasis on reduced tota l - fat 1 I N T R O D U C T I O N and saturated-fat intakes. However , it is we l l k n o w n that change t o w a r d healthier eating behaviours is not easy to achieve. Indeed, many believe the lack o f "adherence" to cholesterol- lower ing nutr i t ional therapies has l imited their widespread appl icat ion in reducing the prevalence o f C H D . A review o f the relevant l i terature reveals that this prob lem is associated w i t h our l imi ted knowledge about the dietary change process and h o w to influence or change individuals ' eating behaviours and promote long- term maintenance o f such changes. Wh i le numerous theories and models have been developed in attempts to understand and predict health behaviour and behaviour change processes, very f e w are appropriate fo r understanding preventive l ife-style behaviour changes. Indeed, according t o B r u h n (1988) " w o r k i n g w i t h asymptomatic individuals to alter l ife-style r isk factors offers very different problems and therefore requires intervention models that go beyond those used in the t radi t ional treatment o f patients mot ivated by sickness" (p. 79). Similarly, f e w o f the t radi t ional theories or models apply to dietary change processes. A n except ion is the Stages o f Change model wh ich has been instrumental in revealing that change involves a series o f interventions, processes or techniques that accumulate over t ime. Tradi t ional ly nut r i t ion education research has focused on the determinants o f dietary behaviour, as we l l as program design, implementat ion and evaluat ion in order to learn more about helping people make dietary changes. A th i rd aspect o f nu t r i t ion educat ion r e s e a r c h — the actual process o f dietary change—has essentially been ignored unt i l recently. Hav ing a better understanding o f h o w individuals go about making changes to their diets and ident i fy ing the major concerns and barriers they confront when making changes w i l l contr ibute t o the 2 I N T R O D U C T I O N effectiveness o f interventions that encourage individuals to init iate a change in their behaviour, and maintain those new behaviours over the long-term. The purpose o f this study was to increase our understanding o f the process o f l ip id -lower ing dietary change as experienced by hyperl ipidemic adults w h o were actively t ry ing to reduce their b lood l ip id levels th rough dietary change. The objectives o f the study were to : • describe h o w hyperl ipidemic adults managed their eating o ident i fy the personal and environmental factors wh ich shaped the process o f dietary change as experienced by adults w i t h hyperl ipidemia • ident i fy coping strategies informants devised dur ing the change process in response to personal and/or environmental factors • generate a theoretical f ramework o f the factors inf luencing the process o f dietary change t o reduce b lood l ip id levels A grounded theory design using qualitative methods formed the basis o f this study fo r t w o reasons. First, I was operating f r o m a constructivist paradigm w i t h the assumptions that real i ty is constructed and shaped by the human mind and that the process o f dietary change could not be understood independently o f the context o f individuals' l ives. Second, the study was exploratory and emphasized the discovery o f novel or unanticipated f indings. A lso , t o best understand the process o f dietary change i t was necessary to study i t f r o m the point o f v i e w o f the individuals experiencing the phenomena. This thesis presents the methods, results and discussion related t o this research project. The general organizat ion includes: a review o f the relevant l i terature in Chapter T w o ; an overv iew o f the study's objectives, research strategy and methods in Chapter Three; the presentation o f the results, theoretical f ramework and conceptual model in Chapter Four ; and 3 I N T R O D U C T I O N a discussion of the study's main findings, their implications for research and practice, and the study's limitations in Chapter Five. 4 L I T E R A T U R E R E V I E W CHAPTER 2: BACKGROUND AND LITERATURE REVIEW Recent trends of promoting health and preventing disease through changes in health-related behaviours are particularly relevant to chronic life-style diseases, such as coronary heart disease (CHD). The following discussion identifies the controllable life-style-related risk factors for CHD and reviews the evidence that lowering blood cholesterol levels results in reduced risk of CHD. In light of this information, the current emphasis of reducing the risk of CHD by adopting cholesterol-lowering dietary changes is outlined and the components of a heart healthy diet are presented. Experts believe that designing intervention programs to yield desirable eating pattern changes can best be done with an understanding of relevant theories of dietary behaviour change (Glanz et al., 1990; Bowen et al., 1994); consequently, an overview of several theories and models traditionally used to understand and study health behaviours is provided. Finally, recent work in the area of dietary change is presented. This section includes a review of factors identified as facilitators or barriers to making changes and/or maintaining those changes, an overview of compliance research, and a brief look at the few studies which have examined the process of dietary change. 2.1. Coronary Heart Disease, Blood Cholesterol and Diet The issue of heart health has gained increasing prominence on the national agenda as CHD continues to be Canada's leading cause of death and illness. Despite declines in mortality rates for heart disease and stroke (British Columbia, 1995; Health Canada, 1995), in 1994 diseases of the circulatory system contributed to more deaths across Canada than any other cause, accounting for 40% and 36% of deaths for women and men, respectively 5 L I T E R A T U R E R E V I E W (Statistics Canada, 1996). O f these deaths, 5 1 % o f the w o m e n and 6 1 % o f the men died from ischemic heart disease, and 2 3 % o f the w o m e n and 16% o f the men died from cerebrovascular disease. I n Br i t i sh Columbia, heart disease and stroke accounted fo r 2 5 % o f deaths in 1995 (Br i t i sh Columbia, 1995). W h e n grouped together, diseases o f the c i rculatory system remained the leading cause o f death in Br i t ish Columbia, account ing fo r 3 7 % o f the to ta l deaths in 1995. I n contrast, all sites and types o f cancers were responsible fo r 2 7 % o f the to ta l deaths in 1995. Overal l , the cost o f cardiovascular disease in terms o f health, qual i ty o f l i fe and product ive capacity continues to be unacceptably h igh (Heal th Canada, 1995). W h e n considering the r isk factors for heart disease, Canadian populat ion-based cross-sectional surveys conducted between 1986 and 1992 found that 6 4 % o f Canadian adults had one or more o f the major control lable r isk factors fo r cardiovascular disease and 4 3 % had h igh b lood cholesterol levels (MacDona ld et al, 1992; Heal th Canada, 1995). Ano the r study found that 2 3 % o f all Canadians are overweight (Canada: Joint Steering Commit tee, 1996). Moreover , many o f the same practices that endanger Canadians' cardiovascular health also contr ibute to other types o f illnesses ( for example, certain types o f cancer, and lung and l iver disease) such that the long- term benefits o f r isk reduct ion could extend in to other areas o f non-communicable disease (Heal th Canada, 1995). Understandably, much research has been conducted to determine the best strategies fo r reducing the r isk factors o f C H D and preventing the disease. The f o l l o w i n g discussion highl ights t w o important issues related to this research. First, C H D r isk factors are discussed w i t h an emphasis on the increased r isk associated w i t h elevated b lood l ip id levels. Second, the ro le o f dietary modif icat ions to reduce the risk associated w i t h elevated l ip id levels is 6 L I T E R A T U R E R E V I E W addressed. Final ly, ongoing controversies regarding the efficacy o f dietary modi f ica t ion to l ower l ip id levels and the importance o f general lifestyle modi f icat ion are out l ined. 2.1.1. C o r o n a r y H e a r t Disease R i s k Fac to rs The r isk factors fo r C H D are generally divided into those that can and cannot be control led. Uncontro l lable r isk factors include genetics, gender and age. Control lable r isk factors, o r those that individuals may be able to reduce or eliminate, include smoking, elevated b lood cholesterol levels, hypertension, obesity and sedentary behaviour. O f these factors, elevated b lood cholesterol has received the most attention. Obesity is also o f concern because other r isk factors, such as elevated b lood cholesterol, hypertension and diabetes mell i tus, tend to cluster around the obesity risk factor. Epidemiological , animal, metabolic, genetic and clinical studies have demonstrated that elevated b lood cholesterol is a major risk factor fo r C H D ( L a Rosa et al., 1986; K r i s -E ther ton et al., 1988; M c N a m a r a and Howe l l , 1992). I n particular, the Nat iona l Hear t , L u n g and B l o o d Inst i tu te 's L i p i d Research Clinics Coronary Pr imary Prevent ion Tr ia l ( L R C - C P P T ) conclusively showed that lower ing elevated b lood cholesterol levels actual ly reduced the incidence o f C H D ( L a Rose et al., 1986). A f te r ten years, "a t - r i sk" subjects receiving a cholesterol- lower ing drug achieved a 9 % greater reduct ion in b lood cholesterol levels than "a t - r i sk" controls. They also had a 19% lower rate o f C H D . These results suggested that i n individuals at a h igh risk due to elevated b lood cholesterol, each 1 % reduct ion in b lood cholesterol levels yields about a 2 % reduct ion in C H D rates ( L a Rosa et al., 1986). A s a result o f the accumulat ing evidence, a Consensus Panel convened by the Nat iona l Inst i tute o f Hea l th in the Un i ted States considered the in format ion and, according t o L a Rosa et al., 7 L I T E R A T U R E R E V I E W concluded that " i t has been established beyond a reasonable doubt that l ower ing definitely elevated cholesterol levels ... w i l l reduce the r isk o f heart attacks due to C H D " (p. S51). Be fore discussing h o w l ip id levels are classified to indicate r isk fo r C H D , I w i l l rev iew the atherogenic potential o f the various l ipoprotein particles wh ich transport cholesterol and tr iglycerides th rough the b lood. A s fat is removed from non-atherogenic very l o w density l ipoproteins ( V L D L ) , smaller l o w density l ipoproteins ( L D L ) are formed. These particles are the most atherogenic. C H D risk increases as elevated tota l cholesterol and LDL-cho les te ro l ( L D L - C ) levels increase. H i g h density l ipoproteins ( H D L ) , o n the other hand, have a protect ive funct ion; hence, the level o f HDL-cho les tero l ( H D L - C ) is negatively related to C H D risk. Overal l , to ta l cholesterol, L D L - C , and H D L - C are strong predictors o f C H D risk. The relationship between triglycerides and C H D is less we l l defined than that fo r cholesterol. W h e n considered independently o f other r isk factors, elevated tr iglycerides appear to be posit ively correlated w i t h r isk fo r C H D . Generally, V L D L (the pr imary l ipoprote in carrier o f tr iglycerides in the b lood) is not considered atherogenic; however Hayden (1986) noted that many patients w i t h C H D have hypertr ig lycer idemia w i t h elevated V L D L . H e also suggested that high triglycerides may be due to overproduct ion o f V L D L as a result o f delayed clearance o f t r iglyceride-r ich V L D L remnants and that L D L - C of ten is also increased due to increased conversion o f V L D L to L D L . Treatment o f individual patients depends on their r isk status or the l ike l ihood o f developing C H D in the relatively near future. Fo r many years, classif ication by to ta l cholesterol and L D L - C levels was used as an indicator o f C H D r isk (Canadian Consensus Conference o n Cholesterol, 1988). M o r e recent evidence indicates that fo r pr imary 8 L I T E R A T U R E R E V I E W prevent ion in adults w i thou t evidence o f C H D i t is better to base ini t ial classif ication o n to ta l cholesterol and H D L - C levels as i l lustrated in Figure 2.1 ( N C E P , 1994). Fo r individuals w i t h desirable blood cholesterol, the level o f H D L - C determines the appropriate fo l l ow-up . F o r individuals w i t h borderline-high blood cholesterol, the level o f H D L - C and the presence or absence o f other r isk factors determine the fo l low-up. Individuals w i t h high blood cholesterol should proceed direct ly to l ipoprotein analysis. L ipopro te in analysis provides the L D L - C level, w h i c h is v iewed as the other key index fo r making decisions about the treatment o f adults w i t h o u t evidence o f C H D (Ernst et al, 1988; N C E P , 1994). The classification guidelines fo r L D L - C are i l lustrated in Figure 2.2. The new guidelines by N C E P assert that drug therapy should be considered only i f elevated L D L - C persists after an appropriate tr ial o f dietary modi f icat ion. Recent evidence indicates that d rug therapy can be delayed in young adult men (<35 years) and premenopausal w o m e n w i t h L D L - C levels between 4.1 to 5 .7mmol /L (or 160 to 2 2 0 m g / d L ) w h o are otherwise at l o w r isk fo r C H D in the near future. O n the other hand, other individuals w i t h less severe elevations o f L D L - C and fewer than t w o other r isk factors may be candidates fo r d rug therapy, such as those w i t h diabetes mell i tus or a fami ly history o f premature C H D ( N C E P , 1994). I f required, drug therapy should be added to dietary intervent ion, not substituted fo r it. 2.1.2. Lipid-Lowering Dietary Modification A l t h o u g h the pr imary purpose o f the L R C - C P P T was to compare the effects o f an active l ip id- lower ing drug to a placebo, the Consensus Panel went on to recommend that elevated b lood cholesterol levels should be reduced pr imar i ly by dietary means ( L a Rosa et 9 L I T E R A T U R E R E V I E W Measure nonfasbng total blood and HDL cholesterol Assess other nonlipid CHD risk factors Desirable blood cholesterol -H of<5.2mmol/L HDLof>0.9rmiol/L HDLof<0.9mmol/L Borderline-high blood cholesterol of 5.2-6.2rrmol/L HDL of > 0.9 rrmol/L and fewer than tvw risk factors * HDL of < 0.9 rnmol/L or two or more risk factors * High blood cholesterol of > 6.2 mmol/L * CHD Risk Factors Positive Age Man > 45 years VNfoman > 55 years or premature menopause wthout estrogen replacement therapy Family history of premature CHD Smoking Hypertension HDL cholesterol of < 0.9 mmol/L Diabetes Negative HDL cholesterol >1.6rnmol/L Repeat total cholesterol and HDL-C analysis in 5 years Provide general education materials (dietary modification, physical activity, and other risk-reduction activities) Follow-up \Mth general education materials (dietary modification, physical activity, and other risk-reduction activities) Reevaluate in 1 to 2 years Repeat total and HDL cholesterol measurement Reinforce nutrition and physical activity information Do lipoprotein analysis Figure 2.1 To ta l and FfDL-cholesterol classification o f adults w i t h o u t evidence o f CFfD (adapted f r o m N C E P , 1994) 10 L I T E R A T U R E R E V I E W Fasting lipoprotein analysis Desirable LDL cholesterol of < 3.4 mmol/L Borderline-high-risk LDL cholesterol of 3.4-4.1 nrnol/L High-risk LDL cholesterol of >4.1 mmol/L fewer than two risk factors * two or more risk factors * Do clinical evaluation Evaluate for secondary causes (when indicated) Evaluate for familial disorders (when indicated) Consider influences of age, sex, and other CHD risk factors Repeat total cholesterol and HDL-C analysis in 5 years Provide general education materials (dietary modification, physical activity, and other risk-reduction activities) Provide information on the Step 1 Diet and physical activity Reevaluate patient in one year Repeat lipoprotein analysis Reinforce the need for appropriate dietary modification and physical activity • I Initiate Step 1 or Step 2 diet see Figure 2.1 for CHD risk factors Figure 2.2 LDL-cho les te ro l classification o f adults w i thou t evidence o f CFflD (adapted from N C E P , 1994) 11 L I T E R A T U R E R E V I E W al, 1986). Hopk ins and Wi l l iams (1986) also report that at the populat ion level, the potent ial f o r changes in dietary habits t o reduce the incidence o f C H D is enormous. The second repor t o f The Exper t Panel on Detect ion, Evaluat ion, and Treatment o f H i g h B l o o d Cholesterol i n Adu l t s ( N C E P , 1994) emphasizes dietary intervention, along w i t h regular physical act iv i ty, as the cornerstones o f cholesterol lower ing in individuals w i thou t established C H D , and recommends delaying a l i fet ime o f expensive drug therapy fo r as long as possible. Be fore discussing the expected magnitude o f reduct ion in b lood l ip id levels and possible explanations fo r indiv idual variat ions fo l low ing dietary modif ications, I w i l l out l ine the dietary factors w h i c h influence b lood cholesterol and tr iglyceride levels. 2.1.2.1. Cholesterol Lowering Dietary Factors M u c h research has been done to determine the effect o f specific nutr ient variables on tota l , L D L and H D L cholesterol levels. Epidemiological data indicate that diets h igh in fat, and l o w in fibre, f rui ts and vegetables contr ibute to increased r isk o f chronic disease, inc luding heart disease. O f these dietary variables, the quality and quanti ty o f fat have received the most at tent ion and are the most consistently significant determinants o f to ta l cholesterol, L D L - C , H D L - C , and the incidence o f heart disease. T w o other major dietary factors that consistently contr ibute to h igh levels o f b lood cholesterol include a high intake o f dietary cholesterol and an imbalance between calorie intake and energy expenditure leading to obesity ( N C E P , 1994). I n the Un i ted States a reduct ion in dietary fat was designated as having flagship importance in improv ing public health (Danford and Stephenson, 1991). I n part icular, the evidence l ink ing saturated fat intake w i t h elevated b lood cholesterol and the r isk o f C H D is considered to be among the most persuasive o f all diet/disease relationships (Heal th and 12 L I T E R A T U R E R E V I E W Welfare Canada, 1990). M c N a m a r a and H o w e l l (1992) report that " there is l i t t le quest ion that h igh intakes o f saturated fat ty acids are related to elevated plasma L D L cholesterol levels and increased coronary heart disease r isk across populat ions" (p.348). They caut ion, however , that the relationship between saturated fat and elevated L D L - C levels w i t h i n populat ions remains less clear. Nevertheless, the current recommendations are that the Canadian and Amer ican diet should include no more than 3 0 % o f to ta l calories as fat and 10% as saturated fat (Heal th and Welfare Canada, 1990; N C E P , 1990). W h e n compared to saturated fat, dietary cholesterol usually is not as inf luential i n affect ing levels o f b lood cholesterol, al though some individuals are hypersensitive to dietary cholesterol. Recently, some investigators have proposed that dietary cholesterol may have an atherogenic effect independent o f any effects o f plasma l ipoprote in cholesterol levels ( M c N a m a r a and H o w e l l , 1992). Ei ther way, a reduct ion in cholesterol intake normal ly accompanies a reduct ion in tota l fat and saturated fat intakes. A n imbalance between calorie intake and energy expenditure leading to obesity contr ibutes to h igh b lood l ip id levels because obesity is accompanied by increased secretion o f V L D L particles, wh ich is fo l lowed by increased conversion o f V L D L to L D L . Obesity also raises tr iglycerides and b lood pressure, increases the r isk fo r diabetes mell i tus, and lowers H D L - C . Conversely, weight loss reduces V L D L particles, L D L - C and tr iglycerides, decreases the r isk fo r diabetes mellitus, and raises H D L - C . Therefore, reducing to ta l fat intakes not only helps lower saturated fat intakes, but more important ly may p romote weight loss in individuals w h o are overweight. I n fact, w i thou t simultaneous weight loss obese individuals may not be able to reduce L D L - C sufficiently by adopt ing a cholesterol - lower ing 13 L I T E R A T U R E R E V I E W diet because i t does not correct the underlying metabolic defect (Denke and Grundy, 1994). Similarly, the response to a cholesterol- lowering diet is enhanced in obese individuals w h o simultaneously lose weight. For these reasons, bo th weight loss and regular physical act iv i ty are extremely important elements o f therapy fo r elevated b lood cholesterol ( N C E P , 1994). I n general, hyperl ipidemic adults are instructed to f o l l o w the w ide ly accepted Amer ican Hear t Associat ion's step-1 diet (Table 2.1). This diet calls fo r the reduct ion o f the major and obvious sources o f fat, saturated fat and cholesterol in the diet ( N C E P , 1994). Indiv iduals already fo l low ing a step-1 diet or w h o are unresponsive to this diet may require more r igorous low- fa t ( < 3 0 % ) and low-cholesterol ( < 300mg/d) diets t o achieve target b l o o d l ip id levels (Canadian Consensus Conference on Cholesterol, 1988; N C E P , 1994). I n these cases, a step-2 diet o r even a step-3 diet as described by H a q and colleagues (1995) may be more appropriate (Table 2.1). Accord ing to the N C E P report (1994) these diets require "carefu l at tent ion to the who le diet so as to reduce intake o f saturated fat and cholesterol t o a minimal level wh i le maintaining an acceptable and nutr i t ious d ie t " (p. 1340). I n addi t ion to Table 2.1. Dietary Therapy of High Blood Cholesterol step-1 step-2 Step3 Tota l fat (% dietary energy) Saturated fat (% dietary energy) 30 10 30 7 <30 <7 Cholesterol (mg/d) 300 200 <200 To ta l Calories T o achieve and maintain desirable we igh t 14 L I T E R A T U R E R E V I E W reducing saturated fat and cholesterol, these diets emphasize the choice o f f ru i ts , vegetables, grains, cereals; and legumes, as we l l as poul t ry, fish, lean meats, and low- fa t dairy products t o ensure var iety and nutr i t ional adequacy. Wh i le the evidence is less conclusive, studies have also indicated a ro le fo r other nutr ients in reducing the r isk o f C H D (Kr is-Ether ton et al, 1988; Connor and Connor, 1990; N C E P , 1994). These include monounsaturated fat, polyunsaturated fat, omega-3 fat ty acids, trans fat ty acids, fibre, complex carbohydrates and alcohol. W h e n substituted fo r saturated fat in the diet, bo th monounsaturated and polyunsaturated fat ty acids lower b l o o d cholesterol levels. Monounsaturated fat ty acids, wh ich are abundant in vegetable oils such as ol ive o i l and canola o i l , reduce b lood cholesterol levels by lower ing L D L - C w i thou t l ower ing H D L - C . Polyunsaturated fat ty acids, on the other hand, consistently lower bo th L D L and H D L cholesterol. A l t hough monounsaturated and polyunsaturated fats are beneficial w h e n compared t o saturated fat, they stil l have a high caloric density and i f used in excess may cause weight gain. Consumpt ion o f omega-3 fat ty acids, commonly found in fish and fish oils, has consistently been associated w i t h a l o w incidence o f C H D . A l t h o u g h some metabol ic studies indicate that omega-3 fat ty acids lower to ta l and L D L - C , the evidence is no t complete and i t is not k n o w n h o w the experimental evidence translates to omega-3 fat ty acid levels in the diet (Connor and Connor, 1990). Regardless, substituting fish fo r f o o d h igh in saturated fat is an effective strategy fo r reducing the saturated fat content o f the diet. W i t h respect to trans fat ty acids, i t seems they raise L D L - C nearly as much as saturated fat ty acids. D ie ts h igh in f ibre and/or complex carbohydrates have also been associated w i t h a l o w incidence o f C H D . A l though i t is di f f icult to assess the importance o f fibre i tse l f because h igh 15 L I T E R A T U R E R E V I E W fibre diets are also usually l o w in fat, soluble fibre ( f r o m oat, oat bran, legumes, pect in, psyl l ium, and selected gums) has been found to have a beneficial effect on b lood l ip id levels. W h e n consumed in large quantities, i t lowers bo th to ta l cholesterol and L D L - C w i t h o u t l ower ing H D L - C . Even i f b lood lipids are not direct ly affected, inc luding fibre-rich foods should help reduce the saturated fat content o f the diet. There is also no evidence that a l o w incidence o f C H D is a direct effect o f a high intake o f complex carbohydrates, however, more l ike ly i t is the low- fa t content o f these diets that is the factor. Similarly, i t is d i f f icul t t o separate the metabol ic effects o f carbohydrates from those o f fibre, since diets h igh in one are usually h igh in the other (Heal th and Welfare Canada, 1990). Final ly, studies have demonstrated that moderate alcohol consumption (7 to 14 oz per week) is protect ive against the incidence o f C H D and has a beneficial effect on H D L - C levels ( N C E P , 1994). However , i t also increases b lood tr iglyceride levels. Overal l , scientists are fair ly certain that tota l b lood cholesterol and L D L - C levels are increased by saturated fat and obesity. A lso H D L - C is reduced by low- fa t , high-carbohydrate diets, a h igh B M I , and lack o f activi ty, and is increased by dietary fat, physical act iv i ty, we ight loss in the overweight , alcohol, and smoking cessation. The role o f other dietary factors, as we l l as the fu l l range o f mechanisms by wh ich dietary modi f icat ion may reduce the r isk fo r C H D are not completely understood. I t is generally believed that a heart healthy diet must be l o w in to ta l fat and saturated fat and should contain fish, as we l l as be h igh in carbohydrate and fibre. Fur thermore, maintaining an ideal body weight and part ic ipat ing in regular physical act iv i ty are essential elements in the nonpharmacological therapy o f elevated b lood cholesterol 16 L I T E R A T U R E R E V I E W ( N C E P , 1994). Recommending increased alcohol consumption to favourably change H D L - C remains controversial because o f the adverse effects associated w i t h alcohol intake and abuse. 2.1.2.2. Triglyceride Lowering Dietary Factors I t seems that hypertr iglyceridemia increases the r isk fo r C H D because o f the increased conversion o f V L D L to L D L - C (Hayden, 1986). I n terms o f dietary factors, tr iglycerides i n V L D L (endogenous hypertr iglyceridemia) are increased by excess calories, especially the p ropor t i on o f calories f r o m refined or simple carbohydrates, and by alcohol. They are lowered by omega-3 fat ty acids found in fish oils and by very h igh intakes o f soluble fibre. Chy lomic ron tr iglycerides (exogenous hypertr iglyceridemia) are sensitive to fat and alcohol intake and are lowered by l imi t ing fat intake to 50g or less daily, o r to less than 2 0 % o f calories. A l c o h o l should also be restricted, and weight cont ro l w i t h caloric restr ic t ion and regular physical act iv i ty is helpful ( N C E P , 1994). 2.1.3. Expected Magnitude of Cholesterol Reduction M a n y studies have been conducted and reviewed to estimate the magni tude o f reduct ion wh ich can be expected fo l low ing dietary modi f icat ion (Bae et al, 1993; Denke and Grundy, 1994; N C E P , 1994; C o x et al, 1995; Denke, 1995; H a q et al, 1995). Metabo l ic studies indicate that when saturated fat is < 7 % o f calories and dietary cholesterol is <200mg per day, the expected tota l b lood cholesterol reduct ion is approximately 1 0 % t o 2 0 % (Kr i s -E ther ton et al, 1988). Further dietary modif icat ions, such as increasing soluble fibre, may lead t o addit ional reductions o f 1 % to 10%. Another way o f put t ing i t , is that f o r every 1 % decrease in saturated fat calories and 1 % increase in carbohydrate calories, to ta l b lood 17 L I T E R A T U R E R E V I E W cholesterol levels w i l l decrease 8 % and H D L - C levels w i l l fal l 0 .7% ( M c N a m a r a and H o w e l l , 1992). M c N a m a r a and H o w e l l also point out that fo r every decrease o f 1 uni t i n B M I (a we igh t loss o f approximately 3 kg ) , total cholesterol levels w i l l decrease 1.3% and H D L levels w i l l increase 1.3%. Overal l , studies in high-r isk individuals have demonstrated a 4 % to 1 7 % reduct ion in to ta l cholesterol levels (Denke, 1995). Free-l iv ing individuals f o l l o w i n g a diet similar to a step-1 diet have obtained a reduct ion o f 3 % to 1 4 % ( N C E P , 1994). A theoretical model developed using a " typical Amer ican w o m a n " having to ta l b lood cholesterol and H D L -C levels o f 5 .4mmol /L (207mg/dL) and 1.5mmol/L (56mg/dL) respectively, demonstrates that f o l l o w i n g a step-1 diet, losing 10 k g and exercising regularly cou ld l ower b lood cholesterol levels by about 12 .5% and increase H D L - C levels by about 15% (Kr is -E ther ton et al., 1995). Reasons fo r such variable responses to dietary modi f icat ion and apparent incongru i ty i n the l i terature are presented below. Be fo re examining w h y the cholesterol- lowering response is variable, i t is impor tant to ment ion w h y the magnitude o f cholesterol lower ing achieved by free-living populat ions can fal l short o f metabolic w a r d study predictions. Denke (1995) suggests the discrepancy results from differences in h o w metabolic wa rd subjects and free-living individuals undertake dietary modi f icat ion. Fo r example, whi le metabolic wa rd subjects have no choice in diet assignment, free-living individuals may find i t di f f icult to change their diet. Similarly, wh i le metabol ic w a r d subjects are fed a precisely defined diet, free-living individuals must decide h o w to make changes in f o o d intake (and these changes may not always achieve the desired reduct ion o f dietary saturated fat and cholesterol). Finally, whi le the intake o f metabol ic w a r d subjects can be direct ly assayed, the intake o f free-living individuals relies on self-reported dietary intakes 18 L I T E R A T U R E R E V I E W that may not accurately reflect t rue intake. Denke concludes that the apparent success o f free-l iv ing individuals to lower their cholesterol levels is influenced by all three factors. W h e n the goals o f dietary modi f icat ion are not achieved, t w o assumptions are common: a) individuals are not "comp ly ing" or "adher ing" to the diet (i.e., blame is placed on individuals and i t is believed they should " t r y harder") and b) dietary therapy is an ineffective approach. Wh i le bo th o f these assumptions may be true in some instances, other factors w h i c h contr ibute to inadequate cholesterol responses fo l l ow ing dietary modi f ica t ion should also be considered. 2.1.3.1. Variable Responses to Dietary Modification A n impor tant consideration wh ich contributes to inadequate cholesterol responses fo l l ow ing dietary modi f icat ion is the variable cholesterol- lowering response w h i c h depends o n several factors. First, individual var iat ion in the magnitude o f the response is frequently related t o the ini t ial l ip id status o f individuals and the extent t o w h i c h b lood cholesterol levels are elevated. Typical ly, those w i t h higher b lood cholesterol levels ini t ial ly usually experience the greatest response to dietary modif icat ion. However , wh i le individuals w i t h severe elevations o f L D L - C of ten do respond to dietary modi f icat ion, the cholesterol - lower ing achieved may be insufficient t o adequately lower L D L ^ C (Denke and Grundy, 1994). Thus, a combinat ion o f diet and drug therapy is usually recommended. Fur thermore, we igh t reduct ion may considerably enhance the responses o f many individuals. Second, the response depends on the type o f diet (especially the amount o f fat and cholesterol) individuals were consuming pr ior t o dietary modi f icat ion. That is, a step-1 o r step-2 diet may not be that different from the "no rma l " diet o f some individuals; hence, l ip id 19 L I T E R A T U R E R E V I E W levels w i l l not respond to "d iet modi f icat ion." For example, Bae and colleagues (1993) proposed that the relatively l o w baseline intake o f fat and cholesterol repor ted by hypercholesterolemic adults younger than 50 years explained w h y their plasma l ip id responses actually exceeded their baseline levels after fo l low ing a step-1 diet f o r 18 weeks. This study emphasizes the importance o f assessing the baseline diet o f hyperl ipidemic adults in order to ascertain the recommended level o f modif icat ion. For hyperl ipidemic individuals normal ly consuming levels o f fat and cholesterol similar to the step-1 diet, this practice w i l l help prevent discouragement o f apparent dietary failure and may l imi t the tendency to resort t o d rug therapy before an adequate t r ia l o f diet can take effect. Final ly, inter individual responsiveness to dietary modi f icat ion varies, such that the b lood cholesterol levels o f some individuals are inherently resistant to dietary modi f ica t ion despite g o o d adherence to a step-1 or step-2 diet ( L a Rosa et al., 1986; Denke and Grundy, 1994; N C E P , 1994). A l t hough the mechanisms fo r this resistance are not w e l l understood, there is l i t t le doubt that genetic factors contr ibute (Denke and Grundy, 1994). Some experts in the field speculate that genetic variations and polymorphisms in the apol ipoproteins, enzymes involved in intravascular processing o f the l ipoproteins, and/or l ipopro te in receptors may be involved (McNamara and H o w e l l , 1992). Regardless o f the mechanism, diet-resistant hyperl ip idemic individuals usually require some f o r m o f drug therapy in addi t ion to dietary modi f icat ion. Weigh t reduct ion may also enhance the responses o f some individuals. A t this t ime the only w a y to determine the inherent responsiveness o f an indiv idual is by t ry ing dietary modi f icat ion. Nonetheless, Denke and Grundy (1994) estimate that only about one quarter o f 20 L I T E R A T U R E R E V I E W patients w i l l be poor responders to dietary modif icat ion, whi le three quarters w i l l be g o o d responders, p rov id ing they adhere to a cholesterol- lowering diet. Overal l , i n addi t ion to the degree o f "compl iance," the magnitude o f reduct ion in b lood cholesterol levels fo l low ing dietary modi f icat ion depends on l ip id levels and dietary habits before start ing the diet, whether or not weight loss accompanies dietary modi f icat ion, as we l l as inherent biological responsiveness. 2.1.3.2. The Effectiveness of Dietary Therapy I n spite o f the strong support for dietary therapy fo r the prevent ion o f C H D , considerable debate stil l exists regarding the efficacy o f dietary modi f ica t ion t o lower l ip id levels. Fo r dietary interventions to be effective, Temple and Walker (1994) declare " i t must be suff iciently v igorous to achieve a drop in b lood cholesterol o f at least 6%, though considerably more is preferable" (p. 450). H a q and others (1995) note that a reduct ion in cholesterol from 6 .5mmol /L to 5 .2mmol /L (a change from high blood cholesterol t o desirable blood cholesterol) requires a cholesterol fall o f 20%. M a n y studies have looked at the plasma l ip id response t o a cholesterol- lowering diet in hypercholesterolemic adults (Bae et al, 1993; Denke and Grundy, 1994; Cox et al, 1995) and reviews o f the evidence are available (Denke, 1995; H a q etal, 1995). H a q and colleagues (1995) considered all published randomized contro l led clinical tr ials o f 6 months durat ion or longer and concluded: the step-1 diet has only a modest and generally non-signif icant effect o n serum cholesterol whether it is employed as individual intervent ion, popula t ion advice, o r in a combined individual and populat ion approach ... the mean cholesterol response is a 1-2% reduction, and not the 10-25% reduct ion suggested in many guidelines" (p. 606). 21 L I T E R A T U R E R E V I E W A rev iew o f tr ials look ing at the step-3 diet (i.e. a r igorous low- fa t diet) f ound that serum cholesterol levels were reduced substantially by 6 .5 -15 .1%. However , H a q and others caut ioned that step-3 diets are of ten exceedingly di f f icul t t o implement and are poor ly to lerated, as demonstrated by the fact that they are not recommended, o r even ment ioned, i n recent guidelines fo r managing hyperl ipidemia. Conversely Denke (1995) found that all tr ials o f at least 150 subjects demonstrated that dietary therapy ( w i t h a step-1 d iet ) can effectively lower cholesterol levels in high-r isk individuals. I n these trials concomitant we igh t loss and cigarette cessation may account fo r the enhanced lower ing observed; nonetheless, Denke concluded a cholesterol- lowering diet can be effective as long as dietary modi f ica t ion is maintained. Overal l , the question concerning the effectiveness o f dietary modi f ica t ion t o suff iciently lower cholesterol in order to prevent C H D remains unanswered. A s ment ioned above, the cholesterol- lowering response to dietary modi f icat ion is variable and the only w a y to determine the inherent responsiveness o f an individual is by t ry ing dietary modi f icat ion. Wh i le elevated b lood cholesterol has received the most attent ion, the value o f focusing efforts o n reducing b lood cholesterol levels has also been questioned (Temple and Walker , 1994). E f fo r ts to lower b lood cholesterol levels through r igorous dietary modi f ica t ion should cont inue to play a major role in the prevent ion o f C H D , however, i t is impor tant to remember that there are other major r isk factors involved in the causation o f C H D and that r isk increases markedly w i t h each addit ional r isk factor. Hence, elevated b lood cholesterol levels should not remain the pr inciple focus o f clinical guidelines aimed at prevent ing C H D . F o r maximal benefit, other "cont ro l lab le" aspects o f lifestyle (such as smoking, lack o f exercise, obesity, stress, and hypertension) should also play a role in the prevent ion o f C H D ( N C E P , 1994). 22 L I T E R A T U R E R E V I E W Temple and Walker (1994) maintain that " the successful prevent ion o f C H D demands a concerted attack o n all o f these factors" and that dietary modi f icat ion should be part o f a more general "al tered lifestyle approach" aimed at preventing other Western diseases (e.g. diabetes, stroke and var ious cancers) in addit ion to C H D (p. 452). Unquest ionably, a mult i factor ial intervention or l ifestyle approach can make a bigger impact o n overal l morta l i ty rates than one aimed at a single r isk factor (Heal th Canada, 1995). I n addi t ion t o dietary modi f icat ion, the panel o f the Canadian Consensus Conference o n Cholesterol (1988) encourages "enough physical act ivi ty to achieve cardiovascular fitness," as we l l as " the balance o f energy intake and energy expenditure ... t o maintain body weight in the acceptable range" and recommends that all o f the r isk factors fo r C H D be addressed in the context o f health p romot ion programs (p. 6). Similarly in the Un i ted States, the N C E P (1994) emphasizes weight loss, regular physical act ivi ty and "o ther r isk- reduct ion act iv i t ies" as extremely important elements o f therapy fo r elevated b lood cholesterol. Wh i le i t seems that health professionals can achieve the greatest gains by target ing mul t ip le r isk factors, t o be successful they require a better understanding o f behaviour change processes. G iven the importance o f dietary modi f icat ion in the prevent ion o f C H D as we l l as reduct ion o f r isk fo r other major chronic diseases, understanding the dietary change process in part icular and the factors inf luencing i t w i l l fur ther improve efforts to help individuals make behaviour changes. The discussion above indicated that many dietary variables are involved in cholesterol- lower ing dietary modif icat ion. I n order fo r individuals to mod i fy complex eating behaviours Caggiula (1989) believes they must have a clear understanding o f the behaviours that need to be changed, however, rather than confront individuals w i t h an array o f nutr ients 23 L I T E R A T U R E R E V I E W that must be modi f ied, she reasons that nut r i t ion education or intervent ion programs should be designed to maximize the process o f behaviour change. Designing interventions that y ield desirable eating pattern changes can best be done w i t h an understanding o f relevant theories o f dietary behaviour change and an abil i ty to put them into practice (Glanz et al., 1990). Consequently, before rev iewing studies that explore the processes o f behaviour and dietary change, theories commonly used to understand and predict behaviour change by health and nut r i t ion educators are discussed. 2.2. Health Behaviour Theories Heal th behaviour theories can help health professionals understand the nature o f targeted health behaviours, and help them identify the most suitable targets fo r behavior change as we l l as the methods fo r faci l i tat ing change (Glanz and Rimer, 1995). Fo r nut r i t ion educat ion to be effective, practit ioners and researchers need bo th t o understand health behaviours related t o nut r i t ion and to t ransform that knowledge in to useful strategies fo r health enhancement (Glanz and Eriksen, 1993). The fo l l ow ing discussion reviews some o f the more c o m m o n health behaviour theories wh ich have been applied to nu t r i t ion interventions, inc luding the Heal th Be l ie f M o d e l , Theory o f Reasoned Ac t i on , L o c u s o f Cont ro l , Social Cogni t ive Theory, Stages o f Change, Di f fus ion o f Innovat ions, and P R E C E D E . A basic assumption o f most o f these theories is that behaviour is mediated th rough cognit ions, such that what w e k n o w and th ink affects h o w w e act (Glanz and Rimer , 1995). Fur thermore, many o f them are based on expectancy-value models o f mot iva t ion. The central concept o f expectancy-value models is that people are more l ikely to take act ion i f they perceive that the act ion w i l l lead to the expected outcomes or anticipated consequences they 24 L I T E R A T U R E R E V I E W value or desire (Contento et al, 1995). That is, among alternative behaviours ( inc luding the op t ion o f not tak ing action) people choose the behaviour they believe w i l l p rov ide them w i t h the m a x i m u m number o f good outcomes and the min imum o f number o f bad outcomes. The f irst three theories reviewed be low are often described as expectancy-value theories. M u c h o f the w o r k surrounding the predict ion o f preventive health behaviour or iginated w i t h the H e a l t h Be l i e f M o d e l ( H B M ) in an attempt to understand w h y individuals d id o r d id not engage in a w ide variety o f health-related activities (Hochbaum, 1981 ; Janz and Becker , 1984; Gochman, 1988; Rosenstock, 1990; Al l ison, 1991). A l t h o u g h the model has undergone modif icat ions to better address more complex behaviours such as eating, in its basic f o r m i t included three factors wh ich influence individuals' readiness to act o r mot iva t ion to engage in preventive behaviour: perceived threat, perceived benefits and perceived barriers. Perceived threat o f disease (seen as a key determinant o f mot ivat ion) is determined th rough considerat ion o f a) the perceived susceptibility o f contract ing a health cond i t ion in the absence o f special actions and b) the perceived severity o f that condi t ion in terms o f the seriousness o f medical and social consequences i f contracted or left untreated. Under tak ing a recommended behaviour was also based on weighing the perceived benefits o f tak ing act ion against the perceived barriers or potential negative aspects o f a part icular health action. The extent t o w h i c h an individual values health was later seen as another impor tant factor o f the model . Overal l , perceived susceptibility and perceived barriers were the factors most closely related t o preventive health behaviour (Janz and Becker, 1984). Recently, the concept o f self-eff icacy was added to the H B M to increase its explanatory power (Rosenstock et al, 1988). Self-efficacy was developed by Bandura and 25 L I T E R A T U R E R E V I E W colleagues t o explain the sense o f self that determines an indiv idual 's ef for t t o change behaviour. Efficacy expectation is an individual 's confidence in his/her abil i ty t o successfully per fo rm a specific behaviour in a specific situation in order t o produce a desired outcome. I t is impor tant t o emphasize that i t is one's beliefs about capabilities that inf luence behaviour rather than the actual capabilities. Overal l , Bandura and colleagues predicted that perceived self-efficacy w o u l d affect what people choose to do ( in Reid, 1995), and determine h o w much effort they w o u l d expend on a task and h o w persistent they w o u l d be in the face o f obstacles ( in Salazar, 1991). A n in-depth review found that self-efficacy was a strong predictor o f bo th shor t - term and long- term success (Strecher et al., 1986). Inc lud ing self-efficacy i n the H B M helped explain the modif icat ions required fo r long- term lifestyle behaviour changes (Rosenstock, 1990). That is, fo r lifestyle behaviour changes t o succeed, not only must individuals " feel threatened by their current behavioural patterns (perceived susceptibil i ty and severity) and believe that change o f a specific k ind w i l l be beneficial by result ing in a valued outcome at acceptable cost, but they must also feel themselves competent (self-eff icacious) t o implement that change" (p.45). The advantages o f greater self-efficacy include higher mot iva t ion in the face o f obstacles and better chances o f persisting over t ime outside a situat ion o f fo rmal supervision (Glanz and Rimer, 1995). The H B M is l imi ted to accounting fo r as much o f the variance in indiv iduals ' health-related behaviours as can be explained by their attitudes and b e l i e f s — i t ignores other forces w h i c h influence health actions, such as habits, social norms, as we l l as economic and/or environmental factors (Janz and Becker, 1984). Indeed, studies using H B M variables that employ mul t ip le regression procedures account fo r only a l o w propor t ion o f the variance i n 26 L I T E R A T U R E R E V I E W behaviour (A l l ison, 1991). Furthermore, the model was based o n the premise that health is a highly valued concern or goal fo r most people, and that cues to act ion are w ide ly prevalent (Janz and Becker, 1984). A jzen and Fishbein's T h e o r y o f Reasoned A c t i o n identif ies and defines key variables that affect an indiv idual 's intentions to act. The basic premise o f the theory, w h i c h l inks beliefs and attitudes to behaviour, is that people are rat ional beings w h o consider their actions before deciding to per fo rm or not per form a behaviour (Salazar, 1991). Essentially, the strength o f a person's intent ion to per form a specific behaviour is thought t o be a func t ion of: a) the att i tude t o w a r d the behaviour and b) the influence o f the social environment or general subjective norms o n the behaviour (Mu l len et al, 1987; Carter, 1990). A t t i t ude t o w a r d a behaviour is determined by an individual 's beliefs about the consequence o f the behaviour (e.g., " H o w strongly w o u l d y o u agree or disagree that sweet foods are fat tening?") weighted by an evaluat ion o f the importance o f the outcome (e.g., " H o w impor tant to y o u is contro l l ing your we ight?" ) . The influence o f subjective norms o n a behaviour is determined by an indiv idual 's normat ive bel ief about what salient others th ink he or she should do (e.g., "Does your doc tor th ink y o u should cut d o w n on the amount o f sweet foods y o u eat?") weighted by the indiv idual 's mot iva t ion to comply w i t h those people's wishes (e.g., " H o w impor tant is i t fo r y o u to please your doctor?") . Intentions to engage in specific behaviours have been shown to be successful predictors o f changes in eating behaviour and diet ing (Gochman, 1988). A s an extension o f the theory, Ajzen's T h e T h e o r y o f P l a n n e d B e h a v i o u r includes a th i rd factor w h i c h determines the strength o f a person's intent ion to pe r fo rm a specific 27 L I T E R A T U R E R E V I E W behaviour. This cons t ruc t—perce ived behavioural cont ro l—encompasses indiv iduals ' att i tudes about the ease or di f f icul ty o f performing a part icular behaviour. Several experts believe the concepts o f perceived cont ro l and self-efficacy are closely l inked and may operate together i n preventive health behaviour (Strecher et al, 1986; A l l i son, 1991 ; B r o w n e l l and Cohen, 1995b). A s stated above, self-efficacy represents efficacy expectations. Perceived cont ro l , o n the other hand, is more related to outcome expectations. Overal l , i f expected outcomes are desirable and perceived to be attainable (i.e., personally control lable), i t is hypothesized that individuals w i l l more l ikely be mot ivated t o change their behaviour, as long as they have confidence in their abil i ty to accomplish such change. I n other words , an indiv idual 's mot iva t ion or intent ion to take action is influenced by his/her perceptions o f h o w di f f icul t the behaviour is and his/her abil ity to per form the behaviour successfully (Simons-M o r t o n et al, 1995). B rowne l l and Cohen (1995b) suggest that having greater personal cont ro l may lead to enhanced self-efficacy, wh ich in tu rn may lead to changes in health behaviour. A l t h o u g h these t w o theories provide methods fo r systematically ident i fy ing issues that are most impor tant to an individual 's decision about per forming a specific behaviour, they are l imi ted by the assumption that behavioural intent ion is the immediate determinant o f behaviour and that all other factors that influence behaviour are mediated th rough intent ion (Carter, 1990). That is, demographic, personality and other socio-psychological variables are expected t o inf luence intent ion only th rough the other components o f the mode l ( M u l l e n et al, 1987). I n Weiner 's L o c u s o f C o n t r o l dimension o f A t t r ibu t ion Theory, the personal cont ro l construct is concerned w i t h the degree o f power an individual believes he/she has over events. 28 L I T E R A T U R E R E V I E W A n internal locus of control refers to individuals w h o perceive that events are a consequence o f their o w n actions o r are under their personal control , whi le an external locus of control refers t o individuals w h o perceive that events o r outcomes in their l ives are subject t o the cont ro l o f others o r are beyond their personal control . I n general, the locus o f cont ro l is der ived f r o m experience in attempting to contro l factors in the environment. Cond i t ion-specific measures o f perceived contro l have demonstrated that the higher the perceived cont ro l over disease, the greater the probabil i ty that individuals w o u l d take actions to prevent disease (A l l ison, 1991). Whi le an individual 's perceived cont ro l (or lack o f cont ro l ) over l i fe events has important implications fo r health education, A l l i son (1991) emphasizes that " there are l imitat ions o n the degree to wh ich individuals can contro l their l ives and, specifically, their heal th" (p. 146). W i t h respect to health education programs that attempt t o t ra in " in terna l i ty " o r the bel ief that events are under one's personal contro l , he states: . . . individuals w h o have l i t t le opportuni ty to exhibit cont ro l i n their l ives i n general should not be expected to believe they have cont ro l o f health o r disease, o r to take preventive act ion ... i t is not simply a lack o f indiv idual mot iva t ion to engage in preventive activities, but rather a compl icated scenario in w h i c h bo th objective and subjective factors interact t o make such behaviours unl ikely (p. 150). Bandura 's Social C o g n i t i v e T h e o r y (SCT) is one o f the most w ide ly recognized and applied models w i t h respect t o health behaviour; however, its value is most appreciated i n the context o f direct ing behavioural change (Olson and Kel ly , 1989). A central assumption o f this theory is that behaviour is dynamic and depends on socio-environmental and personal constructs that influence each other and behaviour simultaneously (Perry et al., 1990) This b i -direct ional interact ion is referred to as reciprocal determinism. SCT also holds that behaviour 29 L I T E R A T U R E R E V I E W is determined by expectancies and incentives. Consequently, i t offers mul t ip le educational approaches t o behavioural change, including environmental and personal change strategies. Prochaska and DiClemente 's Stages o f C h a n g e framework addresses an indiv idual 's mot ivat ional state o f readiness to change or attempt to change t o w a r d healthy behaviours. The idea that people vary in their readiness to change emerged from substantial research by Prochaska and DiClemente in the area o f smoking cessation and substance abuse; however , recent studies have demonstrated that this idea also applies to nut r i t ion behaviour ( B o w e n et al, 1994; Glanz etal, 1994; Greene etal, 1994; Sandoval etal, 1994; N o l a n , 1995; Sporny and Contento, 1995). The central assumption o f the framework is that behaviour change is a dynamic process invo lv ing several distinct stages. A t any t ime, individuals are at vary ing levels o f mot iva t ion, or readiness to change and can be placed in one o f five stages along a cont inuum o f change readiness: a) precontemplation (when individuals are unaware they have a prob lem or are not interested in or unwi l l ing to change), b) contemplation (when individuals are th ink ing about changing in the near future), c) preparation (when individuals are determined or mak ing a plan to change), d) action (when individuals are act ively modi fy ing their habits and/or their environment), and e) maintenance (when individuals are maintaining the new, healthier habits). N o t only are individuals at various stages along this con t inuum o f change readiness, but they can enter or exit at any point. Similarly, individuals are believed to recycle and repeat stages rather than move through them in a straight line. Relapse occurs when individuals revert t o an earlier stage. W o r k surrounding Stages o f Change has been instrumental in reveal ing that change involves a series o f interventions, processes or techniques that accumulate over t ime. The 30 L I T E R A T U R E R E V I E W benefits o f this model f o r explaining dietary behaviour change include: a) ident i fy ing that changes in eating patterns involve mult iple steps and adaptations over t ime, b ) def in ing easily measured stages that can be applied to entire populations at all levels o f mot iva t ion and c) having direct implicat ions fo r intervention designs at each stage. Overal l , individuals at dif ferent points in the change process can benefit f r o m different intervent ions (messages, strategies and programs) that are matched or tai lored to their stage at the t ime. Acco rd ing t o Rogers 's D i f f u s i o n o f I n n o v a t i o n s theory, the di f fusion patterns and adopt ion rates o f innovations are determined pr imari ly by the specific characteristics o f those innovat ions, such as relative advantage, compatibi l i ty, complexi ty, f lexibi l i ty, reversibi l i ty, r isk, cost-eff iciency, reusabi l i ty , tr ialabil i ty, and observabil i ty (Or landi , 1986; Glanz, 1993; Glanz and Rimer, 1995). Max imiz ing and emphasizing these characteristics o f innovat ions may improve the chances that they w i l l be adopted (Glanz, 1993; Glanz and Rimer , 1995). Fur thermore, as an extension o f di f fusion theory, theorists have determined that several stages o f funct ional ly differentiated behaviour are involved in the adopt ion process: awareness, interest, evaluation, t r ia l , and adopt ion (Glanz, 1993). I n terms o f nut r i t ion education, efforts to communicate what healthy eating patterns are and h o w they can be incorporated in to everyday l i fe establish those patterns as innovations (Glanz, 1993). Several principles o f d i f fusion theory can improve the effectiveness o f dietary behaviour change efforts. These include selecting an opt imal setting fo r introducing innovations, creating the precondi t ions fo r change, implement ing a demonstrably effective intervent ion early on, and disseminating the innovat ion th rough successful examples (Glanz, 1993) Overal l , d i f fusion theory has 31 L I T E R A T U R E R E V I E W impl icat ions fo r h o w innovations are posit ioned to maximize their appeal such that some or all o f the di f fusion characteristics play a role in the adopt ion o f dietary changes. PRECEDE (an acronym for: predisposing, reinforcing, and enabling constructs i n educational/ environmental diagnosis and evaluation) was developed as a diagnostic f ramework fo r health education and health p romot ion planning. I n contrast t o many other health behaviour models, i t focuses on behaviour that is related to health, not behaviour that is directed t o w a r d health. P R E C E D E takes into account the mult ip le factors that influence health status and helps determine wh ich o f those factors t o target f o r intervent ion. Green and Kreu te r (1991) included three broad categories o f behavioural factors i n the f ramework : predisposing factors, enabling factors, and reinforcing factors. Predisposing factors are those personal preferences and pr ior motives that people br ing t o an educational experience, inc luding knowledge, attitudes, beliefs, values and perceptions that either support or inhibi t behaviour. Self-efficacy is v iewed as a predisposing factor. Enabling factors are objective characteristics o f an individual, community, and environment that faci l i tate o r inhibi t act ion o r behaviour. This includes such things as skills, resources, and the availabil i ty o r accessibility o f certain foods. Reinforcing factors are the rewards or punishments, inc luding social support, that f o l l o w a behaviour o r are anticipated as a consequence o f it. I n general, most enabling factors are environmental, whi le predisposing factors reside in individuals. Changes in predisposing factors are more l ikely to lead to short- term behavioural changes, wh i le changes to enabling and reinforcing factors are required fo r long- term effects (Neumark-Szta iner and Story, 1996). 32 L I T E R A T U R E R E V I E W 2.3. Limitations of Traditional Theories and Models The preceding discussion presented a br ie f overv iew o f some o f the pr incipal health behaviour and behaviour change theories that are being used in research and practice. A l t h o u g h this rev iew did not encompass every model, nor every aspect o f the models, i t does i l lustrate some o f the w o r k that has been conducted in attempts to understand and predict health behaviour and behaviour change processes. O f the theoretical factors discussed above, the most useful factors w i t h respect to dietary change include perceived threat o f a part icular disease, perceived benefits f r o m changing behaviour, feelings o f personal cont ro l , self-efficacy, and social support (Browne l l and Cohen, 1995b). Despite the range o f theoret ical and conceptual approaches wh ich have been developed to help explain health behaviour and the methods that encourage health behaviour change, there are several l imitat ions to these tradi t ional theories and models. First, w i t h respect t o the changes tak ing place in the area o f health p romo t ion and the increasing shift t oward disease prevent ion, B r u h n (1988) asserts that w o r k i n g w i t h asymptomatic individuals to alter lifestyle r isk factors offers very different problems than the tradi t ional treatment o f patients mot ivated by sickness; thus, l ifestyle behaviour modi f icat ion requires intervention models that go beyond those tradi t ional ly used in the treatment o f patients mot ivated by sickness. A second cr i t ic ism o f the various health behaviour models is that they pr imar i ly focus o n individual ly-or iented behaviour change strategies; thereby support ing a v ic t im-b laming ideology (A l l ison, 1982; M c L e r o y et al., 1988). That is, indiv idual ly-or iented behaviour change (o r a lifestyle approach to disease prevention) expects people t o be indiv idual ly responsible at a t ime when they are less able to contro l their to ta l health environment (A l l ison, 3 3 L I T E R A T U R E R E V I E W 1991). Indiv idual ly-or iented behaviour change strategies focus on changing individuals, rather than changing the social and physical environment wh ich serve to maintain and reinforce unhealthy behaviours. Nonetheless, Rosenstock (1990) questions tak ing the posi t ion t o o far the other way: A m o n g those w h o emphasize a reliance on environmental intervent ions to p romote healthful changes are some whose approach is inf luenced by a desire to avoid blaming the vict ims fo r problems presumably not under their personal contro l . Accord ing to this v iew, those w h o are sedentary, w h o smoke, w h o abuse alcohol, w h o have poor dietary practices should not be blamed fo r having their problems (p. 409). A l l i son (1982; 1991) also cautions against tak ing the posi t ion that health status and health behaviour are products o f external forces beyond individual cont ro l and emphasizes that there are many things wh ich individuals can do fo r themselves to improve their health status. A n alternative approach to health behaviour is the ecological perspective. The ecological perspective implies that behaviour results from the interact ion o f bo th indiv idual and environmental determinants ( M c L e r o y et al., 1988). Hea l th p romo t ion interventions that are based on the ecological model target indiv idual factors ( including interpersonal and intrapersonal processes) and social environmental factors ( including organizat ional and communi ty factors, as we l l as public pol icy) . The assumption is that environmental and/or organizational interventions w i l l help create settings conducive to healthy change, wh i le individual level interventions w i l l complement these intervent ions by focusing o n p romot ing knowledge and behaviours fo r healthful practices i n individuals (Glanz and Er iksen, 1993). A l though applying ecological approaches to behaviour change can result in charges o f coercion, this problem can be minimized by actively invo lv ing the target 34 L I T E R A T U R E R E V I E W populat ion in prob lem def ini t ion and selection o f appropriate interventions, inc luding p rogram implementat ion, and evaluation ( M c L e r o y etal., 1988). I n response to the controversy over whether health efforts should be directed pr imar i ly t o w a r d environmental or personal change, emphasis on a mul t i - theory approach is becoming increasingly c o m m o n (S imons-Mor ton et al., 1988; Glanz and Er iksen, 1993; Glanz and Rimer, 1995; H o t z etal., 1995). Glanz and colleagues (1990) emphasized: N o single theory dominates research or practice in health educat ion ... health behaviour and the guiding concepts fo r inf luencing i t are far t oo complex t o be explained by a single uni f ied theory. Ef fect ive health education depends on marshaling the most appropriate theory and practice strategies f o r a g iven si tuat ion (p. 20) . L o o k i n g at mul t ip le theories also "helps us t o keep our minds open and discipl ined at once, result ing i n more effective programs" (Glanz and Rimer, 1995). Indeed, nu t r i t ion educat ion programs based on any one specific health behaviour model are not l ikely t o succeed. Olson and Ke l l y (1989) were unable t o implement interventions based on SCT and state " i n retrospect ( they) should have examined and ut i l ized addit ional learning and behavioural change theories in the design and implementat ion strategies f o r the nut r i t ion educat ion p r o g r a m " (p. 282) . I n fact, one o f the recurrent themes o f Health Behaviour and Health Education (Glanz et al., 1990) is that theories seldom should stand alone, but should be combined fo r opt imal health behaviour change. These experts assert that w h e n theories are w o v e n together, they may have an even greater predict ive abil i ty than when used alone, and may lead t o programs w i t h greater practical power t o stimulate change. Fo r example, the H B M , Stages o f Change or SCT could be used w i th in the P R E C E D E f ramework t o ident i fy 35 L I T E R A T U R E R E V I E W the predisposing, reinforcing and enabling factors that shape behavioural actions and/or the environment and are amenable to change (Rimer, 1990; Glanz and Rimer, 1995). A th i rd l imi tat ion o f the theoretical approaches reviewed above is that they were not developed specifically to understand and predict food-related behaviours and very f e w suff iciently address the process o f dietary change or identi fy the factors that influence the process. Parraga (1990) maintains that an individual 's f o o d behaviour results f r o m interrelationships between biological, individual, ecological, societal and cul tural variables, inc luding the emotional, social and mythical meanings o f food . Aga in , in order t o predict and explain dietary change specifically, a mult i - theory approach appears to offer the most promise (B rowne l l and Cohen, 1995b). O n the other hand, L inco ln (1992) believes that aspects o f health related t o f o o d behaviour deserve "an inquiry model that takes in to account the mul t ip le meanings that individuals may attach to their o w n care, behaviours, att i tudes and pract ices" and that the inquiry models used to investigate complex behaviour and social patterns a l low fo r the display and consideration o f complex interactions (p. 378) . Thus, i t is easy t o understand w h y the health behaviour models described above only account f o r small parts o f the variance in behaviour. Us ing qualitative methods t o explore the dietary change process w o u l d prov ide a deeper and richer understanding o f health-related f o o d behaviours and w o u l d contr ibute to the development o f theories and models that better explain and predict food-related behaviour and dietary change. 2.4. Factors Influencing Dietary Change Being successful at reducing b lood l ip id levels th rough dietary modi f ica t ion is part icular ly challenging fo r many people fo r several reasons. First, the goal o f dietary 36 L I T E R A T U R E R E V I E W in tervent ion to reduce b lood l ip id levels is not a temporary "d ie t , " but a permanent change in habitual f o o d intake and complex eating behaviours. Second, i n contrast t o qu i t t ing smoking w h i c h involves cessation o f the behaviour, B o w e n and colleagues (1994) observed that successful dietary modi f icat ion a) involves changing mult ip le behaviours, b ) is a more cont inuous series o f changes rather than a discrete event (such as sett ing a date fo r qui t t ing smoking) , and c) is not consistently associated w i t h biological o r physical changes (i.e., feedback). Given these challenges, i t is not surprising that changes t o w a r d healthier eating patterns are not easy to achieve and that attempts to promote dietary modi f ica t ion fo r health reasons have been less than impressive (Glanz, 1981; Hochbaum, 1981 ; B ruhn , 1988; Glanz and Mu l l i s , 1988; Gochman, 1988). However , i t is heartening to see experts stating " the v i e w that diet modi f ica t ion is impractical or doomed to failure fo r most patients is not just i f ied ... many individuals have already modi f ied their diets successfully and have obtained substantial and sustained reductions in b lood cholesterol levels" ( N C E P , 1994, p. 1370). T o learn more about helping people make dietary changes, nu t r i t ion educat ion research has pr imar i ly focused on t w o areas: a) the determinants o f dietary behaviour and b) p rogram design, implementat ion and evaluation (Guthr ie, 1994; B a l d w i n and Falcigl ia, 1995; H o t z et al, 1995). Other research has focused on identi fying the factors that p romote change efforts (Caggiula, 1989; McConaghy, 1989; Contento and M u r p h y , 1990). Wh i le k n o w i n g more about these areas can assist health professionals in helping people make changes to then-diets, a th i rd aspect o f nut r i t ion education research—the actual process o f dietary change or h o w people go about making changes to their d ie t s—has essentially been ignored unt i l recently. A n elegant i l lustrat ion o f the relationship between these three aspects o f nu t r i t ion 37 L I T E R A T U R E R E V I E W educat ion research was provided by Shannon (1990) to guide research directed t o improv ing nut r i t ion educat ion practice. Accord ing to the model (Figure 2.3), the determinants o f dietary behaviour impact on the dietary change process. I n turn , a clear understanding o f the dietary change process impacts on the design, implementat ion and evaluat ion o f nu t r i t ion educat ion programs. Final ly, outcomes from the implementat ion and evaluation o f these programs feed back in to the other research areas o f the model. The discussion be low provides an overv iew o f factors that influence dietary behaviour, important considerations w h e n p romot ing dietary change, and factors involved in the process o f dietary change. 2.4.1. The Determinants of Dietary Behaviour Understanding the determinants o f dietary behaviour o r w h y people eat what they eat is the first step in changing dietary behaviour. I n general, food-related behaviour and f o o d choices decisions related to f o o d purchasing, preparation, and consumpt ion are part icular ly complex and are determined or influenced by a dynamic relationship between many indiv idual D e t e r m i n a n t s o f D ie ta ry B e h a v i o u r Dietary C h a n g e Process P r o g r a m D e s i g n I m p l e m e n t a t i o n a n d Eva lua t ion Figure 2.3 Shannon's (1990) conceptual model t o guide nut r i t ion education research. 38 L I T E R A T U R E R E V I E W and environmental factors. Whi le many investigators have examined the determinants o f dietary behaviour (Hochbaum, 1981; Devine and Olson, 1991; Baghurst , 1992; Dev ine and Olson, 1992; Guthr ie, 1994; Canada: Joint Steering Commit tee, 1996), only a b r ie f overv iew o f some o f them is provided here. For more details on the factors w h i c h inf luence dietary behaviour, I recommend Parraga's (1990) review o f the cul tural and indiv idual variables o f f o o d consumpt ion, Furst and others' (1996) conceptual model o f the factors invo lved in the process o f mak ing f o o d choices, and Janas's (1993) conceptual model o f food-related appraisals and considerations. F o o d choices may be influenced to a moderate degree by some broad and vague no t ion about what is supposed to be healthful, however, Hochbaum (1981) maintains they are more frequent ly guided by considerations total ly unrelated to health. I n addi t ion t o basic physiological factors, such as sensory taste preferences, these considerations include social, economic and demographic factors, such as the taste preferences o f others, peer pressure, income, social class, education, l iteracy, ethnicity, and social roles. Other considerations are indiv idual o r personal factors, such as preferences fo r costs, freshness and convenience, and cogni t ive and psychological factors (i.e., h o w individuals conceptualize in format ion about f o o d and/or health). Whi le individuals' knowledge and attitudes related to diet and health are shaped by current sociocultural factors, Hochbaum (1981) also contends that many nut r i t ion-related att i tudes can be traced to chi ldhood experiences (probably because eating patterns begin t o f o r m in infancy). Environmental factors are another consideration, not only w i t h respect t o an indiv idual 's dietary behaviour, but also in terms o f his/her capacity to make choices (e.g., the lures o f advertising and store displays, the available f o o d supply, the cul tural 39 L I T E R A T U R E R E V I E W obsession w i t h leanness as a sign o f beauty). Finally, cultural factors are an impor tant consideration. Hochbaum (1981) maintains that the decisions individuals make about what foods t o eat, h o w to prepare food , when to eat, and even when they feel hungry are most ly learned behaviours that are of ten imbedded in cultural norms. Given some o f the strong considerations listed above, i t is not surprising that dietary behaviours tend to resist any but moderate modif ications. Fo r example, even w h e n people have a fair ly strong health orientat ion, Hochbaum (1981) states: . . .conf l ic t ing motives may often and easily interfere w i t h adherence t o its principles. The w ish to be considered a good host o r hostess may prevent the preparat ion of, and social amenities may prevent a guest from selecting, foods that are believed to be desirable from a health point o f v iew. The desire t o j o i n and be accepted by one's peers may impose on the most conscientious person the need t o eat at places where nutr i t ious foods are not offered (p. S61). B r u h n (1988) fur ther maintains that people are reluctant t o alter patterns o r behaviours that represent power fu l , predictable, and immediate sources o f grat i f icat ion w h i c h are deeply ingrained in social and cultural context. Overal l , w i t h a better understanding o f the factors that influence dietary behaviour, their relative importance, and their relationship to each other, nut r i t ion educators w i l l have a better idea o f h o w to go about changing dietary behaviour. 2.4.2. P r o m o t i n g D i e t a r y C h a n g e Despi te the fact that health practit ioners are we l l aware that knowledge, wh i le necessary, is not sufficient t o change individuals' eating habits (Glanz, 1981 ; Hochbaum, 1981 ; Kr is -E ther ton etal., 1995), the bel ief that p romot ing dietary change is mainly a matter o f st imulat ing mot iva t ion and supplying knowledge persists (Contento et al., 1995). The largely inval id assumptions wh ich guide in format ion disseminating programs are: a) in formed awareness o f the health effects o f nutr i t ion is a potent mot iva t ion fo r people to regulate their 40 L I T E R A T U R E R E V I E W f o o d intake, and b) i t is a lack o f nutr i t ion knowledge that prevents people f r o m eating more rat ional ly (Hochbaum, 1981). Simply provid ing knowledge about nu t r i t ion does no t translate in to recommended practices unless people are ready to make changes. One o f the challenges facing nutr i t ion educators is understanding h o w t o br idge the gap between knowledge and behaviour. Neumark-Sztainer and Story (1996) believe "as nut r i t ion counseling deals w i t h more complex and long- term behaviours, the focus moves from what foods the client should be eating to how t o facil i tate the client in modi fy ing and maintaining these behaviours" (p. 72). Consequently, a great deal o f research has examined h o w dietit ians and other health professionals can better assist people to adopt and/or maintain dietary change (Caggiula 1989; Shannon, 1990; N C E P , 1994; Contento et al., 1995). O f part icular interest is the l i terature pertaining to mot ivat ion o r readiness f o r change, the faci l i tators and barriers o f dietary change, compliance issues, and relapse prevent ion. 2.4.2.1. Motivation or Readiness For Change The fai lure o f free-living individuals to achieve predicted cholesterol lower ing may not only result from a failure to educate individuals about mak ing changes, but also a fai lure to mot ivate them (Denke, 1995). The early bel ief that in formed awareness o f the health effects o f nut r i t ion was a potent mot ivator for people to regulate their f o o d intake was based o n the false assumption that most people value health. I n actual fact, most people consider health to be the means t o achieve and enjoy the other things that happen to be impor tant t o them (Hochbaum, 1981 ; B ruhn , 1988). I n other words , health is a resource fo r everyday l i fe, not the object ive o f l i fe. Accord ing to Hochbaum (1981), "most people are l ikely to engage in part icular behaviours i f they see these as contr ibut ing to their personal goals, regardless o f 41 L I T E R A T U R E R E V I E W whether the behaviours are labeled by health professionals as healthful o r not , o r even whether o r not they are labeled as detrimental to health" (p.S61). This is not to say that some people seem t o value health and do adopt certain health practices or even a l i festyle commensurate w i t h wha t they believe w i l l assure lasting health. However , Hochbaum (1981) maintains that: i n the vast major i ty o f case ... the long-range goals o f assuring last ing health and long l i fe have l i t t le effect on daily l iv ing practices. These daily practices are more influenced by demands made by psycho-social, cul tural , economic, and environmental pressures in their homes and workplaces, and in l ine w i t h their individual, non-health related aspirations, interests, wishes, fears, and goals, (p. S61). Consequently, he stresses that using whatever already strongly influences indiv iduals ' daily conduct w o u l d seem more promising in br inging about changes than appealing t o an apparently relat ively unimportant "heal th mot iva t ion . " Ano ther important factor that dissuades people from changing their l i festyle o r health behaviours is the benefit they derive from the lifestyle and behaviours w i t h w h i c h they have become comfortable. B r u h n (1988) maintains that i t is di f f icul t t o persuade or mot ivate individuals t o g ive up a behaviour or make major changes in the w a y they l ive w h e n the benefits o f such changes are u n k n o w n and the substitutions are of ten v iewed as a punishment or sacrifice. I n other words , the t rade-of f between behaviours o r lifestyles is no t seen as an equal one. B r u h n (1988) also suggests that individuals' choices and decisions about changing l i festyle and health behaviours are influenced by l i fe events (such as the death o f a fami ly member) and stage o f development (e.g., adolescence versus middle aged). Research has demonstrated that having someone close w h o was sick w i t h a serious illness had the least effect on 16 to 24 year olds, but the strongest effect on those 55 and over (McConaghy , 1989). Despi te the fact that l i fe events and stage o f development represent " t imes" o r 42 L I T E R A T U R E R E V I E W "po in t s " w h e n individuals are more receptive to health in format ion and perhaps more mot ivated to change, these factors are not readily amenable to outside influences. G iven the constraints out l ined above, question arise over the best ways t o mot ivate people to make dietary changes. Accord ing to health behaviour theories, "readiness" fo r change exists w h e n a person feels mot ivated to achieve or obtain something strongly desired or prevent something feared from happening and when the indiv idual perceives that the new behaviour w i l l lead to the desired result (Hochbaum, 1981). T o understand the mot ivators fo r mak ing dietary change, Contento and M u r p h y (1990) examined some o f the factors w h i c h inf luenced dietary change in adult shoppers w h o reported having vo luntar i ly made posit ive changes in their diets. The factors wh ich were the most predict ive o f change status (and w h i c h cou ld be interpreted as mot ivators fo r change) included a) percept ion o f personal susceptibil i ty t o diet-related diseases, b) perceptions o f benefits from tak ing prevent ive health actions, and c) the beliefs o f those important t o the survey participants. I n part icular, measures o f outcome expectations (i.e., perceived susceptibil ity and perceived benefits) prov ided a large part o f the explanation as to w h y some people made dietary changes whi le others d id not. Contento and M u r p h y also found that individuals ' perceptions o f their personal vulnerabi l i ty were more l ikely to result in behaviour change rather than being mot ivated by general threat inducing messages. Consequently, they concluded that nut r i t ion educators should emphasize personal vulnerabil i ty by making individuals aware o f their o w n personal and specific health risks (based on their medical histories and dietary behaviours). Others have found that suffering from a serious illness and th ink ing dietary changes might aid recovery mot ivated individuals to make dietary changes (McConaghy, 1989). 43 L I T E R A T U R E R E V I E W I n the context o f Dec i and Ryan's Se l f -De te rm ina t i on T h e o r y , Bo te lho and Skinner (1995) reviewed three kinds o f mot ivat ion including: a) extrinsic motivation (changing because someone else expects change), b) introjected motivation (an internal ized f o r m o f extrinsic mot iva t ion such that individuals th ink they "ough t , " "mus t , " o r " s h o u l d " change their behaviour) , and c) integrated motivation ( in wh ich individuals decide t o change ou t o f a sense o f pure vo l i t ion) . Integrated mot ivat ion is considered the highest f o r m o f mot iva t ion because individuals are act ing in ways that are consonant w i t h their values, beliefs and needs. Bo te lho and Skinner (1995) go on to state individuals are more l ikely to make changes i f health professionals support their autonomy and competence to change rather than using behaviour-cont ro l l ing approaches. Support ing their autonomy and competence to change increases their integrated or intr insic mot ivat ion fo r change in wh ich change arises f r o m w i t h i n out a sense o f pure vo l i t ion , rather than being imposed from external o r internal sources o f obl igat ion. Sel f -Determinat ion Theory also predicts that individuals w i l l respond to var ious interventions according to their disposit ion toward change (Bote lho and Skinner, 1995). These disposit ions include: a) autonomous-integrated ( individuals th ink " I ' m go ing to change because I really want t o . " ) ; b) autonomous-introjected ( individuals th ink " I ought/should/must change.") ; c ) controlled ( individuals th ink " I ' m changing because others to ld me t o . " ) ; and d) indifferent ( individuals th ink "Changing isn ' t important o r relevant t o me at the moment . " ) . I n general, they assert that changes made because o f autonomous- introjected or contro l led disposit ions t o w a r d change are more dif f icult t o maintain and require more reinforcement from others. These understandings o f mot ivat ion have led to the development o f mot ivat ional techniques that consider individuals' dispositions toward change and attempt t o move them 44 L I T E R A T U R E R E V I E W towards an autonomous-integrated disposition. Overal l , such mot ivat ional approaches to behaviour change are based on the assumptions that most individuals k n o w h o w to change and have the skills and competency to change, but that individuals lack mot i va t ion t o change, are no t ready to change, and that individuals decide whether and when to change (Bote lho and Skinner, 1995). 2.4.2.2. Facilitators and Barriers of Dietary Change Another cr i t ical aspect o f developing effective intervent ion programs is understanding h o w factors serve as facil i tators or barriers to change (Kolbe, 1988). E v e n adequate nutr i t ional knowledge and strong motivat ions to translate such knowledge in to practice can falter i n the face o f strong barriers (Hochbaum, 1981). Aga in , the l i terature is abundant w i t h in format ion on var ious barriers and facil i tators to dietary change (Bruhn , 1988; Barnes and Terry , 1991 ; Curr ie etal, 1991; Baghurst, 1992; Schlundt etal, 1994; Barnard et al, 1995; Iszler et al, 1995; L l o y d et al, 1995; Wr igh t , 1995). Before ident i fy ing some o f these factors, i t is important t o identi fy that some factors can act as barriers or faci l i tators depending o n the social si tuation and meaning to the individual. Several studies were reviewed to obtain an overv iew o f the barriers t o dietary change in var ious contexts and situations (Curr ie et al, 1991; Baghurst, 1992; Schlundt et al, 1994; Wr igh t , 1995). The barriers identif ied in these studies included personal barriers ( internal factors more o r less w i th in individuals' direct contro l ) and socio-environmental barriers (external factors w i th in the environments that individuals have l i t t le or no cont ro l over) . Personal barriers included: f o o d preferences (e.g., missing favour i te foods, having cravings, feel ing deprived, perceptions that "heal thy" foods are bor ing foods) , the d i f f icu l ty inherent in 45 L I T E R A T U R E R E V I E W making the change i tsel f (e.g., breaking o ld habits and making new ones), health perceptions (e.g., seriousness, benefits, contro l ) , cook ing skills, disl ik ing the new behaviour and l ik ing the previous behaviour, the fact that the o ld behaviour had a purpose (e.g., t o relieve bo redom or fo r comfor t ) , problems w i t h self efficacy, compet ing priori t ies, and negative emotions. Social-environmental barriers included: availability o f food (i.e., w i th in local grocery stores o r the geographical locat ion, in restaurants, and when travel ing), financial costs (e.g., expense o f foods and f o o d waste), social pressures (e.g., social events, fami ly obl igations, eating patterns and preferences o f family/fr iends), t ime constraints, and culture (e.g., l i fe long habits or upbr ing ing, the meaning o f holidays and special occasions). Other less commonly identif ied barriers also play a role i n efforts to make dietary changes. B r u h n (1988) identif ied that making changes to improve a nonsymptomat ic cond i t ion is di f f icul t t o achieve because often there is l i t t le or no reward ing physical feedback (such as reduct ion o f pain) and i t typical ly elicits only minimal or shor t - term acknowledgment and support by fami ly and friends. Furthermore, the " l i ve fo r today and d o n ' t w o r r y about t o m o r r o w " att i tude prevalent in N o r t h Amer ica, coupled w i t h the h igh expectat ion that sophisticated technology o f medicine can mend almost any health malady that might occur may prov ide individuals w i t h l i t t le incentive to adopt recommended health behaviours (Bruhn , 1988). Ano ther barrier t o behaviour change may be denying that change is even necessary. Fo r example, I rv ine and L o g a n (1994) observed that a large subset o f hypercholesterolemic men in a hypercholesterolemia detection and treatment p rogram conducted in a w o r k i n g adult popula t ion d id not accept the label or denied the diagnosis despite being t o l d they had this problem. I n this study, denial was a significant barrier to health behaviour change. A l t h o u g h 46 L I T E R A T U R E R E V I E W only a small sample o f the l i terature was reviewed, i t is evident that there are a w ide range o f structural, social and environmental barriers to changing eating behaviours. Faci l i tators o f dietary change have been identif ied in several studies (Curr ie et al, 1991; Barnard et al, 1995; Denke, 1995; Sparks et al, 1995). These include: achieving results (e.g., feeling or look ing better, feeling healthier o r f i t ter, losing we igh t ) , anticipating fu ture health benefits, having the support o f fami ly and/or fr iends, having professional support, the patterns o f fami ly and friends (i.e., flexibility about eating habits and wil l ingness to t r y new foods) , enjoying the new eating behaviours, frequent f o l l ow-up , and having a self-ident i ty conducive t o making changes (i.e., identi f icat ion as someone concerned about the health consequences o f what they eat instead o f as someone w h o enjoys pleasures o f eating). Overal l , investigators w h o study barriers and facil i tators o f change of ten state that the challenge is f inding ways to reduce the problems and barriers associated w i t h change and capitalize o n those factors wh ich facil itate change. 2.4.2.3. Compliance Issues and Dietary Change Acco rd ing to tradit ional compliance ideology, noncompliance is v iewed as a fai lure on the part o f the patient t o f o l l o w the doctor 's instructions and is the pat ient 's fault regardless o f the reason. D o n o v a n (1995) presents a number o f further assumptions that are inherent in compliance ideology: a) doctors always make an appropriate diagnosis, b) they k n o w what is best f o r their patients, c) they prescribe effective treatments rationally, d) they are able to impart medical in format ion clearly and neutrally, and e) they are the principle (o r on ly) contr ibutors t o decisions about medications and other treatments. Accord ing ly , the t e r m compliance suggests that patients should obey the doctor 's orders o r instruct ions w i thou t 47 L I T E R A T U R E R E V I E W qualm or question. This concept o f compliance suited the tradi t ional paternalistic model o f medical decision making in wh ich doctors were the authori ty and k n e w what act ion was best fo r the patient. Unfor tunately , this v iew o f medical decision making is sti l l prevalent in the 1990s. I n an article p romot ing the benefits o f patient-focused care Schiller and M i l l e r (1996) repor ted that "du r ing an init ial discussion o f the concept o f patient satisfaction w i t h a group o f cl inical professionals, one highly respected person responded 'Th is is an academic medical centre. W e k n o w what our patients need, that 's our job . Patients aren' t sophisticated enough to k n o w what they need or w a n t . ' " (p. 9). Similarly, Hernandez (1995) repor ted that the diabetes l i terature promotes a conf l ict ing role in that individuals are urged t o " take charge, but comply/adhere" (p. 33). A l t h o u g h there has been a noticeable shift t oward encouraging more patient autonomy and part ic ipat ion in health care decisions (part icularly in chronic disease) D o n o v a n maintains that this concept o f shared decision making has not had any signif icant impact u p o n compliance research. That is, whi le doctors and patients are expected t o part icipate i n discussion about treatment opt ions and come to an agreement on the treatment regimen, patients are sti l l expected to comply w i t h this regimen. Fo r example: . . . fa i lure to obtain expected serum cholesterol lower ing frequent ly indicates inadequate dietary compliance (NCEP, 1994, p. 1365). . . . inadequate long- term compliance remains one o f the major obstacles t o successful dietary therapy (Henk in et al, 1992, p. 1172). A large amount o f research has tr ied to understand and resolve noncompl iance w i t h prescribed medical treatments (West, 1973; Glanz, 1980; Henk in et al, 1992; Barnard et al, 1995; B r o w n e l l and Cohen, 1995a). M a n y possible causes fo r noncompliance have been identi f ied, including the complexi ty o f the regimen, poor communicat ion between health 48 L I T E R A T U R E R E V I E W professionals and patient, economic factors, patients' unresolved concerns about the diagnosis, lack of symptoms, time between following the treatment and its effect, and fear or misunderstanding of adverse effects (Donovan, 1995). Studies have also examined differences in the personal characteristics of compliers and noncompliers (Kouris et al, 1988; Caggiula and Watson, 1992; Crumb-Johnson et al, 1993). While compliance is not consistently associated with age, sex, education, income, intelligence, marital status, or knowledge of disease processes, it is better among those who accept the diagnosis, who believe the diagnosed condition or its sequelae could be serious, who believe the recommended treatment could control the condition at acceptable cost, and who believe they are personally capable of following the treatment (Rosenstock, 1988). Finally, dietitians' effectiveness and their counseling strategies have also often been studied as possible causes for noncompliance (Glanz, 1979; Caggiula, 1989; McCann et al, 1990; Barnes and Terry, 1991; De Looy et al, 1992; Roach etal, 1992; Gilboy, 1994). Compliance research has also focused on factors that make it easier for patients to adhere with medical advice (Butler et al, 1996). As a result, many solutions to noncompliance have been suggested in the literature, including improvement of doctor-patient relationships, modifying the ways in which doctors present information, providing more and better patient education, simplifying the treatments prescribed, and using techniques that encourage patients to follow the treatment (Rosenstock, 1988; Donovan, 1995). Despite this wealth of information on the causes for and solutions to noncompliance, research has consistently found that between 30-50% of individuals fail to comply with medical advice and prescriptions (Donovan, 1995). In terms of dietary interventions for the control of 49 L I T E R A T U R E R E V I E W hypercholesterolemia and hypertension, Glanz (1980) estimated a 13% to 76% rate of adherence. Before becoming concerned about this apparent failure of interventions to promote compliance and blaming individuals for poor compliance, several inadequacies of the traditional conception of compliance need to be addressed. First, it is important to recognize that much of the compliance research was conducted in relation to medical treatments for diagnosed illness. In contrast, lifestyle modification for risk reduction presents a more complex problem for intervention than does compliance with medical treatments for diagnosed illness (Rosenstock, 1988). Unlike illness episodes that are acute, time-limited and accompanied by concrete symptoms, risk of chronic illness usually has an indefinite time span and exists in the absence of visible signs or symptoms (Leventhal et al, 1984). Furthermore, fluctuations in risk status are not readily monitored by the onset and disappearance of concrete symptoms; thus risk remains an abstract concept. Leventhal and colleagues also recognized that "the person at risk for chronic disease must initiate and maintain change over an indefinite period of time toward an uncertain reward, with only signs of failure (i.e., disease symptoms) and without clear objective evidence of progress" (p. 398). Given these concerns, there is greater recognition that it is inappropriate to apply acute models of disease and treatment to risk reduction for chronic disease prevention (Leventhal et al, 1984; Rosenstock, 1988; Donovan, 1995; Hernandez, 1995; Butler etal, 1996). Second, health professionals need to have a better understanding of the complex process of making changes to ingrained and socially reinforced behaviours. Rosenstock (1988) urges health professionals to join in partnership with their clients, particularly in regard to high-risk behaviour modification, because a) a therapeutic alliance is more likely to result in 50 L I T E R A T U R E R E V I E W mutually desired change and b) clients should be free to choose their own lifestyles. Indeed, Donovan (1995) points out that the patient's perspective and role in medical decision making is critically absent from compliance research. While it is usually assumed that patients play a passive role in noncompliance by failing to follow the treatment regimen through ignorance or negative behaviour, Donovan notes that research in the area of social science suggests patients think very seriously about their treatment regimen and many make reasoned decisions about their treatment that can be quite different from the treatment plan advised by the doctor. Compliance research has only recently become interested in the patient's perspective of health and illness. By examining issues in health and health care from the point of view of the patient and focusing on the meanings and reasons that lie behind behaviour, Donovan has found that patients are not "blank sheets" in front of the doctor who meekly await the instructions of doctors: They hold sets of beliefs and theories about health and illness in general, and often about specific problems and treatments as well. They also make their own decisions about how they respond to illness. . . The advice or instruction they receive from the doctor is .... passed through the filter of their existing beliefs. If the doctor's advice concurs with their beliefs, then they are likely to accept it and may well comply. If, on the other hand, this advice conflicts with what they believe to be true or suggests action that is not possible or desirable within the constraints of their everyday lives, then they may fail to comply (pp. 449-450). Consequently, Donovan believes patients do not fail to comply, but choose to take another action. They do not obey or disobey the doctor's orders, but "make their own reasoned decisions about treatments based on their own beliefs, (expectations), personal circumstances, and the information available to them" (p. 443). Also, "in making their decisions about compliance, patients carry out a kind of cost-benefit analysis, weighing the advantages and 51 L I T E R A T U R E R E V I E W disadvantages o f adhering to the regimen" and consider " h o w the treatment fits in to their o w n beliefs and the constraints o f their everyday l ives" (p. 449). Hence, f o r patients w i t h chronic illnesses, "compl iance" per se does not matter t o them. Indeed, Hernandez (1995) found that the pr io r i t y f o r individuals w i t h non-insulin dependent diabetes was l iv ing w i t h diabetes, not str iv ing t o achieve and maintain an educator-defined acceptable b lood glucose level. D o n o v a n maintains that the major i ty w h o do not comply do not feel gu i l ty at not obeying the instruct ions because they w i l l have reached a rat ional and sensible decision w i t h i n the framework o f their o w n lives and beliefs. H e concludes that the concept o f compliance is a false goal and "has no role to play in modern health care systems, where chronic illness and quest ioning patients predominate" (p. 453). Consequently, i t is t ime fo r researchers and health professionals t o acknowledge that patients can and do make reasoned decisions about their health, and in most cases patients are the ul t imate decision maker about their o w n health. 2.4.2.4. Relapse Prevention Strategies The health impact o f dietary modi f icat ion can only be achieved i f desirable behaviours are maintained over a per iod o f t ime. Yet , as the vast body o f compliance l i terature demonstrates, many people w h o make dietary changes eventually re turn to their previous eating behaviour o r relapse. Nonetheless, B rowne l l and colleagues make an impor tant d ist inct ion between " lapse" and "relapse," w i t h lapse referr ing to the process (slips and mistakes) that may or may not lead to a relapse (i.e., a breakdown or set-back i n a person's at tempt to change or modi fy target behaviours) ( in Neumark-Sztainer and Story, 1996). Relapse prevent ion theory encompasses a wide range o f strategies t o teach individuals w h o are t ry ing t o change their behaviour h o w to anticipate and cope w i t h the problems o f relapse. 52 L I T E R A T U R E R E V I E W Indiv iduals are encouraged to develop problem-solving skills t o help strengthen their commitment and abil i ty t o continue new behaviours. Self-management o r sel f -control procedures are also at the heart o f relapse prevent ion strategies. Acco rd ing to Mar la t t and Gordon , "techniques fo r dietary self-management using relapse prevent ion t ra in ing include developing skills t o deal w i t h stressful or challenging situations ( for example, learning t o say no wh i le being a gracious guest), foster ing new cognit ions (att i tudes, at t r ibut ions) about one's abi l i ty t o cont ro l behaviours and developing a daily l ifestyle that includes heal th-promot ing behaviours, such as exercise and stress management techniques" ( in Glanz, 1993, p. 261) . Despi te the negativi ty usually associated w i t h relapse, i t is impor tant t o recognize that relapse may have posit ive consequences. Relapse is associated w i t h dietary f lexibi l i ty, an impor tant dimension o f some patients' beliefs about dietary adherence (Janas et al., 1993). I t is also beneficial i f the experience somehow prepares the indiv idual fo r later success (Neumark-Sztainer and Story, 1996). 2.4.2.5. New Directions for Dietary Change Research Several investigators have been clear about what research is required i n order t o learn more about helping people make dietary changes. Accord ing to Guthr ie (1994) , the challenge and oppor tun i ty facing nutr i t ion education researchers is to pu l l together wha t has been learned f r o m the t w o lines o f research mentioned a b o v e — t h e determinants o f dietary behaviour and program design, implementat ion and e v a l u a t i o n — t o develop a more complete and more uni f ied theory o f dietary behaviour change. However , as an alternative to k n o w i n g more about the determinants o f dietary behaviour and f igur ing out how t o change people 's eating behaviour, several investigators have suggested i t may be more product ive t o examine 53 L I T E R A T U R E R E V I E W what is involved in the actual process of making changes—especially since a clear understanding of the dietary change process will impact on the design, implementation and evaluation of nutrition education programs (Shannon, 1990; Currie et al., 1991). Studies should also be done to investigate the specific strategies that changers have found important for the dietary change process to be carried out successfully (Contento and Murphy, 1990). Trying to understand the factors that sustain health-related behaviours is difficult because the behaviours are embedded within the pattern of daily life (Currie et al., 1991). More than a decade ago, Hochbaum (1981) identified that: More research is needed in the context of people's daily lives in all the complexity and sometimes seeming irregularity and unpredictability of their (eating behaviours) to discover common and recurrent elements which may generate new theories (and) yield practical and promising new approaches to influence individuals' nutrition behaviour (p. S65). Only by knowing how people make changes to their diets can we best understand how to influence or assist with the process. Unfortunately, many of the strategies and enabling factors identified in the literature seem to reflect the perspectives of practitioners, rather than the perspectives of those actually experiencing dietary change. Furthermore, Bruhn (1988) observed that the different approaches educators and researchers have used to promote healthy life-styles have usually been derived from various "theoretical orientations, or the personal interest of the interventionist, rather than appeal to the diversity of values and motivations of the target audience" (p. 80). He believes this as a problem in nutrition education because little is known about the processes of dietary change as experienced by those undergoing such change. Health professionals not only need to ensure their education efforts are successful and that clients comprehend the suggested dietary modifications, but 54 LITERATURE REVIEW they also need t o understand the complex process o f making changes to ingrained and socially reinforced behaviours. Several investigators have begun to examine the process dietary change and the processes involved in making changes. This exci t ing w o r k is presented in the next section o f the review. I t is encouraging to see that many o f these studies examined change processes f r o m the point o f v iew o f those experiencing dietary change. 2.4.3. Understanding the Process of the Dietary Change A s indicated above, choosing to change one's diet is guided by a complex interact ion o f psychological factors, including readiness, wil l ingness, and abil i ty t o change (B rowne l l and Cohen, 1995b). Behaviour change is also influenced by intrapersonal factors, such as knowledge, perceptions, attitudes, mot ivat ion, developmental history, past experience, and skills, as w e l l as factors in the social environment (Glanz and Rimer, 1995) Several aspects o f the dietary change processes are reviewed here: the process o f establishing mot iva t ion fo r change and the process o f actually making changes. W i t h respect t o mot iva t ion fo r change, the process o f establishing self-care behaviours is reviewed. The concept o f self-care was developed to explain the activit ies individuals init iate and per fo rm on their o w n behalf t o maintain health, and wel l -being. Be fore self-care behaviours are adopted, readiness for self-care is necessary (expressed as mot iva t ion , att i tude, or internal resources); however, what makes a person ready to self-manage a chronic illness is poor l y understood. Baker and Stern (1993) studied the development o f self-care readiness among adults w i t h a chronic illness whose course could be contro l led th rough a treatment regimen. They identi f ied several processes involved in self-care readiness and developed a conceptual f ramework to explain its development among the individuals in their study. 55 LITERATURE REVIEW Nonaccomodation to the illness was the starting point f o r the development o f self-care readiness in that all informants responded by rejecting the chronic illness pattern by seeking a cure, looking for scapegoats t o blame fo r their situation, and/or giving up on l ife. The key process in mobi l iz ing the evolut ion o f self-care readiness was finding meaning in chronic illness. This process involved assenting to the illness (i.e., acknowledging its existence, accepting that i t was long te rm and recognizing that i t was not current ly curable) and reframing its implications posit ively. I t al lowed the informants to make sense of self-care teaching and t o perceive themselves as self-care agents having some cont ro l over their illness course. M a k i n g sense o f self-care teachings involved several simultaneous processes, inc luding: a) tuning in (i.e., registering self-care messages by actively l istening t o them), b) integrating var ious strands o f self-care messages together (i.e., perceiving the management o f their illness as a whole) , and c) finding a w a y to incorporate self-care behaviours by making them part o f the rout ine o f l i fe helped the informants acquire the self-care messages. This was di f f icul t because all informants found something about self-care that was unpalatable to them. T o faci l i tate the incorporat ion process, the informants usually found ways or developed strategies to make self-care behaviours easier. Sustained nonaccomodat ion t o the illness reduced the informants ' interest in finding ways to incorporate self-care behaviours. Fo r example, instead o f integrat ing self-care messages, those w h o were unable to accommodate to their illness sometimes adopted discrete aspects o f the self-care messages they received, but they perceived them in a fragmented fashion. Whi le it is impossible to generalize these findings t o others, the study indicated that readiness fo r self-care in chronic illness is a 56 L I T E R A T U R E R E V I E W complex and dynamic process, and emphasized that h o w individuals see themselves i n relat ion t o their illness may be a cri t ical factor in their receptivi ty to self-care teachings. W i t h respect to the process o f actually making changes, B o w e n and colleagues (1994) used the Stages o f Change model to develop an instrument wh ich measured the processes invo lved in changing fat consumption. They found that wh i le the use o f var ious processes increased throughout the stages o f change, not all were used to the same degree: the use o f environmental re-evaluation, nutr i t ional strategies and consciousness raising increased th rough the stages; dramatic relief, behavioural strategies and social support processes were used most f requent ly dur ing the act ion stage; and social l iberation was used frequent ly th rough all the stages. They concluded that the particular processes (o r strategies) used at each o f the stages need to be identi f ied in order to assess the applicabil ity o f their instrument. A l o n g these lines, a qualitative study explor ing hypercholesterolemic adults' experiences w i t h cholesterol lower ing dietary change identi f ied five components w h i c h represented the cognit ive and behavioural aspects o f the part ic ipants' dietary change experiences (Janas et al., 1993). These components included: knowing and finding out; making and using a game plan; eating foods; managing food settings; and checking up. Each one was fur ther characterized by dimensions that explained the var iat ion among the participants. Th is conceptual model provides a f ramework fo r understanding and organizing the processes involved in cholesterol- lowering dietary change and offers d i rect ion to bo th pract i t ioners and researchers interested in improv ing interventions to p romote dietary change. Wh i le the investigators emphasized the complexi ty and variabi l i ty o f the dietary change process and pointed out that a variety o f personal and environmental factors inf luenced the 57 L I T E R A T U R E R E V I E W part ic ipants' dietary change efforts ( including t ime, money, and fami ly f o o d preferences), they v iewed these factors as "external influences" and did not include them in the focus o f the study. Instead, they stated that the roles o f personal and environmental factors in the process o f dietary change needed further investigation. Unfor tunately, disregarding or considering factors as "ex terna l " o r "extraneous" has long been a problem in nutr i t ion-related behaviour research (Hochbaum, 1981). Janas (1993) also explored the ways that cardiac patients managed changes in their food-related practices. She generated a conceptual f ramework w h i c h focused o n individuals ' appraisals o f the food-related situations they encountered. Di f ferent categories o f considerations wh ich were processed in food-related appraisals included: diet and health, social meanings of food and eating, sensory aspects of foods, appetite and hunger, resources, identity, and familiarity. Subcategories o f the considerations were also identi f ied. A n impor tant aspect o f diet and health considerations were individuals ' personal dietary guidelines (i.e., collections o f dietary restrictions and allowances w i t h respect to f o o d components, foods or food events perceived to be personally relevant). I n dif ferent situations the part icipants consciously o r subconsciously assessed w h i c h considerations were impor tant and determined what courses o f act ion were associated w i t h each consideration. Some f o o d -related situations (e.g., evening meals) involved a larger number o f considerations than other food-re lated situations (e.g., weekday breakfasts). Janas reported that f requent confl icts among considerations were apparent, especially between personal dietary guidelines and social considerations or hunger and appetite considerations. 58 L I T E R A T U R E R E V I E W The strategies the participants used fo r coping w i t h diet-related confl icts were ident i f ied as either compliance strategies or accommodation strategies. Wh i le part icipants used bo th types o f strategies, most had a characteristic approach that they used more often. The compliance approach involved efforts to " t r y and stick t o the diet . " Compl iance strategies included: a) implementing dietary restrictions without concession, b ) relying on dietary allowances, c) using foods that "fill up," d) physically avoiding temptation, and e) increasing diet-related consciousness. I n contrast, the accommodation approach involved efforts t o " t r y to balance things out . " Accommodat ion strategies included: a) making acceptable changes in usual practices, b) making concessions in dietary restrictions, c) looking for and experimenting with new ideas, d) balancing consumption over time, e) satisfying hunger and cravings, and f ) increasing consumption of good foods. A l t h o u g h the participants generally had a characteristic approach, participants d id change their approach and at t imes used strategies that were uncharacteristic o f their approach. Overal l , Janas's theoret ical framework enhances our understanding o f food-related practices and may facil i tate discovery o f effective ways to influence the processes that generate food-re lated practices. Deve lop ing strategies also helped the respondents in Wr igh t ' s (1995) study handle a var iety o f situations and maintain a very l o w fat cardiac diet. These strategies, alone or in combinat ion, included: avoiding foods, eating smaller amounts, eating treats, and limiting intake before or after a high fat consumption. I n an extension her study w i t h cardiac patients, Janas and others (1996) examined cardiac patients' beliefs about dietary deviations. Whi le participants believed that everyone "goes o f f " the diet and no one could fo l l ow i t " 1 0 0 % o f the t ime, " they di f fered in whether 59 L I T E R A T U R E R E V I E W they perceived dietary deviations as potential ly detrimental, harmless, o r beneficial. Those w h o v iewed themselves as being "very conscious," "d iscip l ined," " r i g i d , " o r "s t r i c t " about the diet generally t r ied to avoid situations that posed a high r isk fo r deviations from personal dietary guidelines. Those w h o described themselves as " f lex ib le" about the diet and believed the diet needed to be "handled w i t h moderat ion" thought i t was " O K to go o f f sometimes," especially i f they were careful. A few participants believed deviations were beneficial and helped them stay on the diet. The investigators noted that judgments about whether specific episodes o f " g o i n g o f f the diet" were acceptable were based o n personal cr i ter ia fo r frequency of deviation, degree of deviation, and situation in wh ich the deviat ion occurred. Overal l , the studies described above significantly contr ibute to the body o f nu t r i t ion knowledge because they emphasize that dietary change is not an outcome o f a sequence o f events, but a complex process. Furthermore, they provide insight into the processes o f change as experienced by individuals w h o are famil iar w i t h the making dietary changes. 2.5. S u m m a r y Accompany ing the evidence that high b lood cholesterol is a major r isk fac tor fo r CFfD, is the conv ic t ion that dietary change is the method o f choice in contro l l ing popula t ion b lood cholesterol levels and reducing the r isk o f CFfD ( L a Rosa et al., 1986; Connor and Connor, 1990). Indeed, dietit ians feel that nut r i t ion education w i l l be a major component i n health p romot ion , as health practit ioners seek to keep people we l l rather than merely treat the sick (Anderson, 1994). Nonetheless, a review o f the l i terature reveals that knowledge o f the processes o f dietary change is stil l lacking. T o learn more about the process o f dietary change, several investigators agree that the barriers to and enabling factors o f changing eating 60 L I T E R A T U R E R E V I E W behaviours need to be identif ied (Bruhn, 1988; Caggiula, 1989; Curr ie et al., 1991 ; Janas, 1993; Anderson, 1994; B o w e n et al., 1994). A l t hough the studies rev iewed above begin t o ident i fy the factors that hinder or facil itate the process o f dietary change, very f e w ident i fy o r prov ide a complete understanding o f what is involved in the process and the strategies individuals use to overcome barriers. Caggiula (1989) discussed strategies that should be incorporated in to intervent ion programs in order to br ing about change; however, she does not ident i fy strategies that individuals undergoing change use to overcome barriers or enhance enabling factors encountered in everyday experiences. Whi le Janas and her colleagues (1993) ident i f ied five categories o f cholesterol- lowering dietary change that explained the cogni t ive and behavioural aspects o f the part icipants' dietary change experience, various personal and environmental factors were v iewed as "external influences" and were not explored. Consequently, ident i fy ing the personal and environmental factors that facil i tate o r hinder the dietary change efforts, as we l l as the strategies ut i l ized to accomplish change w i l l fill a large gap in understanding o f the process o f dietary change. Janas (1993) provides an interesting and exci t ing theoret ical f ramework that enhances our understanding o f the food-re lated practices o f a select g roup o f cardiac patients. Further examination o f a different g roup o f individuals ' change efforts is important t o further develop a holist ic understanding o f the factors and processes involved in dietary change. 61 D E S I G N A N D M E T H O D S CHAPTER 3: DESIGN AND METHODS This chapter begins w i t h an overv iew o f the research objectives, f o l l owed by a discussion o f the assumptions and rationale fo r a qualitative research design, and an outl ine o f the research strategy. A description o f the procedures used in the study is presented, inc luding sample selection, recruitment, data col lect ion, and data analysis. Final ly, the cr i ter ia f o r j u d g i n g the qual i ty o f grounded theory studies are explained. 3.1. Research Objectives The purpose o f this study was to increase our understanding o f the process o f l ip id -lower ing dietary change as experienced by hyperl ipidemic adults w h o were actively endeavoring to reduce their b lood l ip id levels th rough dietary change. The objectives o f the study were to : • Ident i fy the personal and environmental factors wh ich shaped the process o f dietary change as experienced by adults w i t h hyperl ipidemia. • Ident i fy h o w hyperl ipidemic adults managed their eating. • Ident i fy coping strategies informants devised dur ing the change process i n response to personal and/or environmental factors. • Generate a theoretical f ramework o f the factors inf luencing the process o f dietary change to reduce b lood l ip id levels. 3.2. A Constructivist Paradigm M y phi losophical v iews o f the social w o r l d and h o w to study i t fit closely w i t h the construct iv ist paradigm. Several theoretical and technical assumptions and characteristics 62 D E S I G N A N D M E T H O D S underl ie the construct ivist paradigm including the nature o f reality, the role o f context , the role o f values, and the nature o f t ruth. A fundamental assumption o f construct iv ism is that reality is constructed and shaped by the human mind and changes over t ime (Achterberg, 1988). Const ruct iv ism rejects the v i e w that an object ive reality exists. Instead, i t claims that " rea l i ty " is more in the mind o f the knower . That is, each individual constructs his/her o w n reali ty th rough interpret ing perceptual experiences o f the external w o r l d (Jonassen, 1991). Therefore, constructions are created realities wh ich don ' t exist outside o f the person w h o creates and holds them (Guba and L inco ln , 1989). They are not part o f some "object ive" w o r l d that exists apart from their constructors. Thus, i f w e assume humans construct meaning fo r objects and events by interpret ing their perceptions o f them in terms o f past experiences, beliefs and biases, then each person mental ly represents his/her o w n personal reality (Jonassen, 1991). A n d since people vary, there can be mult iple constructions o f reality. Overal l , construct ivists are relativists. They believe reality exists in the f o r m o f mult ip le mental construct ions w h i c h are socially and experientially based, local and specific, and dependent fo r their f o r m and context on the persons w h o hold them (Guba, 1990). Guba elaborates that " there is no foundat ional process by w h i c h the ul t imate t ru th or falsity o f these several construct ions can be determined" (p. 26). Thus, research stemming from construct iv ism represents the cont inuing search fo r ever more informed and sophisticated constructions. A s Guba stated, i t "a ims to keep the channels o f communicat ion open so that in format ion and sophist icat ion can be cont inuously improved" (p. 26-27) . 63 D E S I G N A N D M E T H O D S A second assumption o f construct ivism is that research is context -bound and involves a hol ist ic perspective in wh ich the phenomenon being studied is "unders tood as a complex system that is more than the sum o f its parts" (Patton, 1980, p. 40) . D ie ta ry change, fo r example, cannot be separated f r o m or understood independently o f the context o f in formants ' l ives (Chapman and Maclean, 1990). A th i rd assumption is that social research is value-laden because i t is characterized by interact ion between the researcher and informants in order to construct meaning from everyday experiences. I n addit ion, since I was the instrument o f bo th data col lect ion and data analysis, m y "personal experiences and insights are an important part o f the inqui ry and cri t ical t o understanding the phenomenon" (Patton, 1980, p. 40). A s a result, i t is assumed that all inquiries are inevitably value- and context-bound because " the knower and the k n o w n are interact ive and inseparable" (Achterberg, 1988, p. 245). Just as i t is assumed that research is context-bound and value-laden, i t is also assumed that " t r u t h " is context-bound. Furthermore, i t is assumed that mul t ip le t ruths are possible because there are mult ip le v iews o f reality in any given s i tua t ion— those o f dif ferent informants, m y o w n as the researcher and the reader or audience (Creswel l , 1994). D u r i n g the research process, the realities o f the informants and researcher are fused in to a single ent i ty such that the f indings are l i terally a creation o f the interact ion process between the t w o (Guba, 1990). Construct iv ist researchers interpret others' interpretations or construct ions o f real i ty and then construct their o w n interpretations o f reality from them. Thus, the same in format ion is subject to many equally plausible interpretations (Guba and L inco ln , 1989). Therefore, unl ike research conducted by positivists or post-posit ivists in w h i c h object iv i ty is 64 D E S I G N A N D M E T H O D S demanded, subjectivi ty characterizes the interactive, context- and value-laden inqui ry process o f studies conducted by constructivists. For constructivists the major purpose o f research is not t o prove or disprove ideas, but to f o r m understandings and establish connections between construct ions offered by others and the interpretations o f the researcher (Guba and L inco ln , 1989). Overal l , construct iv ism "intends neither to predict and cont ro l the ' rea l ' w o r l d nor t o t ransform it , but to reconstruct the ' w o r l d ' at the only point at wh ich i t exists: in the minds o f const ructors" (Guba, 1990, p. 27). I n general, constructivist research is inherently exploratory and emphasizes the discovery o f novel or unanticipated findings. Research from this perspective recognizes and tr ies t o accommodate dist inctly human properties o f the w o r l d that are social as opposed t o physical o r b io logical (Murco t t , 1995). I t tries to tell us about the " w h y " behind statistical correlat ions o f variables. Furthermore, since the meaning o f social phenomena is context dependent i t is best studied from the point o f v iew o f individuals experiencing the phenomena (Bryman, 1984; Chapman and Maclean, 1990; Guba, 1990). F o r these reasons, quali tat ive methods were preferred fo r this study to better understand the complex social process o f dietary change. I t should be apparent from the discussion above that the t e r m qualitative is a methods-level term, not a paradigm-level term. 3.3. Research Strategy Several aspects o f the research were taken into considerat ion w h e n deciding o n a research strategy. First, the research objectives required an examinat ion o f complex social relationships. The purpose o f the study was to identi fy and gain an understanding o f indiv iduals ' rea l -wor ld experiences from their point o f v iew (Patton, 1980; Chapman and 65 D E S I G N A N D M E T H O D S Maclean, 1990). Furthermore, food choices are complex decisions w h i c h are inf luenced by a dynamic relationship between individual and environmental factors. Consequently, an i n -depth understanding o f the context shaping and inf luencing the complex process o f dietary change was crucial fo r discovering the personal and environmental factors that facil i tate or hinder dietary change efforts. Second, my o w n philosophical ou t l ook generated a desire fo r f i rst-hand behavioural in format ion on the process o f dietary change. Final ly, not only is there l i t t le in fo rmat ion in the l i terature pertaining to the process o f dietary change and the decision-mak ing role o f individuals undergoing dietary change, but the factors inf luencing change efforts and the strategies individuals develop to overcome barriers or facil i tate change are not we l l k n o w n and not yet encompassed in theory. 3.3.1. Qualitative Methods T o satisfy the cri teria listed above, qualitative methods were used to study adults' experiences o f cholesterol- lowering dietary change. Qual i tat ive methods accommodate the exploratory nature o f the problem because they are fluid and flexible—they emphasize discovering novel o r unanticipated findings and are open to the possibi l i ty o f al ter ing research plans in response to the f indings wh ich emerge dur ing the research process. Qual i tat ive methods also prov ide greater depth and richer insight into personal perceptions, and permit explorat ion o f qual i ty-of- l i fe and l i fe satisfaction issues. The technical assumptions and characteristics o f the quali tat ive mode o f inqui ry are as fo l lows. First, research techniques are natura l i s t i c—rea l -wor ld situations are studied as they un fo ld natural ly in a non-manipulat ive, unobtrusive and non-contro l l ing manner w i t h a lack o f predetermined constraints imposed on the outcomes (Patton, 1980). A naturalist ic approach 66 D E S I G N A N D M E T H O D S therefore facilitates the identification of the interacting influences that shape behaviour (Olson, 1990). Thus, data collected by qualitative methods are primarily descriptive, reflect a non-judgmental view of the informants as much as possible, and are presented in a narrative form. Second, since constructivists want to identify the variety of constructions that exist and bring them into as much consensus as possible, the qualitative constructivist research process consists of a hermeneutic dialectic: hermeneutic in that individual constructions are depicted as accurately as possible, and dialectic because individual constructions (including my own) are compared and contrasted and informants are confronted with the constructions of others in order to achieve a higher-level construction (Guba, 1990). The process of data analysis used to achieve this is the constant comparative method (Glaser and Strauss, 1967). Finally, the research is characterized by an inductive logic process that relies on an emerging design in which data collection, analysis and interpretation are conducted simultaneously, rather than one that is predetermined and carried out in discrete stages (Chapman and Maclean, 1990; Patton, 1980). Important variables or categories are identified during the research process as they emerge from the data, instead of being identified a priori by the researcher before gathering data. Olson states that an inductive approach to data analysis is "more likely to identify the multiple realities in the data and to make the (researcher-informant) interaction explicit" (p. 465). 3.3.2. Grounded Theory The particular qualitative method used to collect and analyze data was grounded theory. This method was chosen to explore adults' experiences with dietary change because it is well suited to discovering processes, rather than static situations, as it can provide more 67 D E S I G N A N D M E T H O D S complete in format ion on the process variables (Achterberg, 1988; Johnson and M o r s e , 1990; Strauss and Corb in , 1990). A basic canon o f a grounded theory approach is that the f indings are generated f r o m the data; thereby a l lowing theory to emerge dur ing the research process. This is central t o the grounded theory approach wh ich rejects stating theory a priori and then p rov ing it. Instead, the researcher begins w i t h an area o f study and wha t is relevant to that area is a l lowed to emerge (Strauss and Corbin, 1990). Consequently, wh i le the ini t ia l research quest ion is broad, i t becomes progressively narrowed and more focused dur ing the research process, as concepts and their relationships are discovered to be relevant o r irrelevant to the emerging theory. That categories w i l l be discovered dur ing the research process, rather than organized in to prescribed conceptual categories before the study begins, gives rise to a second canon o f grounded t h e o r y — d e s i g n flexibility. Decisions about the kinds and sources o f data t o be used are made throughout the research process and cannot be specified in advance. The place where data col lect ion begins is specified and a "best guess" as to h o w data col lect ion proceeds is of fered (Chapman and Maclean, 1990). A s a study progresses, data col lect ion and analysis procedures are subject to ongoing revision in response t o the emerging findings. Consequently, the design or focus o f a study changes somewhat th roughout the research process in response to an increasingly refined research question (Marshal l and Rossman, 1989). Ano ther feature o f grounded theory is that the findings w i l l not jus t answer the quest ion " W h a t is go ing on here?" but w i l l answer the question " W h a t is go ing on and w h y ? " (Becker, 1993). Whi le descriptive studies are l imited to a descript ion o f wha t is happening in a social sett ing, grounded theory studies are characterized by conceptual depth. They prov ide 68 D E S I G N A N D M E T H O D S conceptualizations o f tentative relationships between variables and abstract explanations o f under ly ing social processes. Grounded theory methods involve mult iple stages o f data col lect ion and analysis o f in format ion. That is, data col lect ion, coding and analysis go on simultaneously. T w o pr imary characteristics o f a grounded theory design are constant comparison o f data w i t h emerging categories, and theoretical sampling o f different groups to maximize the similarit ies and the differences o f the data. Constant comparison is the method used to generate grounded theory by jo in t l y coding and analyzing the data. This method draws attention to the similarit ies and differences in the data. A s categories emerge, their fullest generality and meaning are cont inual ly being developed and checked fo r relevance. The constant comparative method involves four stages: a) compar ing incidents applicable to each category, b) integrat ing categories, c) del imi t ing the theory, and d) w r i t i n g the theory (Glaser and Strauss, 1967). These stages are used together dur ing analysis, w i t h each stage prov id ing continuous development t o its successive stage unt i l analysis is terminated. Constant comparison, when used jo in t l y w i t h theoret ical sampling, forces the researcher to consider much diversity in the data and facil i tates the generat ion o f theories o f process, sequence and change. Theoret ical sampling is the process o f data col lect ion whereby the emerging theory controls fur ther data col lect ion. A s the data are simultaneously col lected, coded and analyzed i t becomes obvious where data are missing and where gaps in the analysis exist. Essentially, analysis guides data col lect ion because the categories and theory that emerge point to what data t o collect next and where to collect it. Again, design f lexibi l i ty is impor tant because i t 69 D E S I G N A N D M E T H O D S al lows the researcher to decide where sampling w i l l be the most relevant to the emerging theory. The theoretical sampling and constant comparison procedures mean that a grounded theory approach is not just an inductive process, but involves bo th induct ive and deductive processes (Becker, 1993; Patton, 1990). I n the first stage o f analysis, the researcher induct ively searches fo r the important variables and questions, result ing in a theory that emerges from the data. Deduct ive analysis characterizes the next stage in w h i c h the researcher tests induct ively generated hypotheses by theoretical ly sampling in attempts t o con f i rm or disprove the exploratory findings. The research process continues w i t h the researcher induct ively explor ing fo r other, over looked hypotheses or unmeasured factors. 3.4. Research Procedures The fo l l ow ing sections describe the specific research procedures used in this study including sample selection, informant recruitment, data col lect ion, and data analysis. A l t h o u g h these research procedures are described separately, they were conducted simultaneously and cyclically throughout the research process. 3.4.1. Sample Selection Several investigators have noted that individuals undergoing dietary change are the most knowledgeable about the process and the ways to manage i t successfully w i th in the context o f their lives (Curr ie etal, 1991; Maclean and Oram, 1988). Hence, individuals w h o were "exper ts " about the dietary change process (because they were at tempt ing t o change or mod i f y their diets) served as informants fo r this study. Accord ing t o the principles o f a grounded theory approach, the informants were selected on the basis o f the relevance o f their 70 D E S I G N A N D M E T H O D S experiences t o the emerging categories and theory. Ini t ial ly, sampling was opportunist ic , i n that informants were selected because o f their availability, as we l l as their involvement in and abil i ty t o art iculate and explain the phenomenon under study (Chapman and Mac lean, 1990; Spradley, 1979). However , as the theory began to emerge, purposive sampling directed in formant selection. M y goal was to capture the range o f diversity on the phenomenon o f study; thus, informants w i t h specific characteristics were selected t o obtain a range o f characteristics in attempts to validate or disprove the emerging theory. Wh i le i t was assumed that hypercholesterolemic adults w o u l d be more mot ivated to make dietary changes than people in the general populat ion, i t was no t assumed that they w o u l d all be equally mot ivated to change their diets. Consequently, the main inclusion cr i ter ion o f the study was that individuals be in the action stage o f dietary c h a n g e — d e f i n e d as " t r y ing to change one's d iet" ( B o w e n et al., 1994). That is, only those individuals w h o repor ted they were actively modi fy ing their eating behaviour and/or environment were recrui ted and selected as informants fo r the study. There is general consensus in the l i terature that successful long- term behavioural change requires at least a six mon th per iod ( B o w e n et al, 1994; Caggiula, 1989; Rimer, 1990). Thus fo r the informants t o have had sufficient experience w i t h the process o f dietary change, only individuals w h o had been at tempt ing change fo r at least six months were selected as informants. T o target individuals w h o were commi t ted to or at least t ry ing to make changes, informants were recrui ted from the out -patient l ip id cl inic at St. Paul 's Hospi ta l in Vancouver, Br i t i sh Columbia.-I n a grounded theory approach, theoretical saturation is the cr i ter ion used t o judge w h e n to stop sampling data. I n other words, the sample size is considered sufficient w h e n 71 D E S I G N A N D M E T H O D S addit ional data do not yield new informat ion or saturation is reached. Once the core categories and theory perspective were identif ied, i t became clearer wh ich categories required fur ther explorat ion. Whi le not all categories require the same depth o f inquiry, core categories require fu l l saturation. Fo r this study, fourteen informants were sufficient t o prov ide saturation o f the core categories. 3.4.2. Informant Recruitment In i t ia l ly recruitment posters and flyers were displayed in the wa i t ing r o o m o f the l ip id cl inic (Append ix A ) . Fo l low ing poor response to this approach, the dietit ians at the clinic were asked to refer individuals to me. They approached individuals w h o : a) had h igh b lood l ip id levels (i.e., hypercholesterolemia and/or hypertr ig lycer idemia) b) were t ry ing to change their diet in order t o reduce their b lood l ip id levels c) had not had a heart attack or exhibited other signs o f heart disease d) were fluent in Engl ish e) demonstrated an interest in the study and a wil l ingness to be interv iewed A s the study progressed, inclusion was also based on theoretical sampling in order t o obtain a diverse sample group. Hence, recruitment later in the study targeted individuals w h o were diagnosed w i t h h igh l ip id levels f o r less than f ive years. L i v i n g situation was also taken into considerat ion to ensure variety w i th in the sample. T o assist w i t h recruitment, I attended the clinic in order t o meet potent ial informants immediately and answer their questions about the study. Prov ided the cr i ter ia specified above were met, individuals were introduced to me pr ior t o or fo l l ow ing the diet i t ian's counseling session. I again explained the purpose o f the study to potential informants and assessed their interest in part ic ipat ing and commitment t o being interviewed several t imes. A t this t ime a 72 D E S I G N A N D M E T H O D S screening questionnaire was completed to assess compat ibi l i ty w i t h inclusion cr i ter ia (Append ix B ) . This second recruitment approach proved to be very successful. Recru i tment t o o k place between October 1995 and December 1996. I n tota l , 30 individuals were screened fo r part ic ipat ion in the study, and o f these, 14 individuals (7 men and 7 w o m e n ) were included. Reasons fo r not including the others fo l low ing recrui tment included the presence o f heart disease, canceled appointments, length o f t ime since diagnosis (>15 years), and personal t ime constraints. Several individuals were excluded because o f their similarit ies w i t h those w h o were already part o f the study (e.g., another single w o m a n l iv ing o n her o w n ) . Part ic ipat ion in the study was entirely voluntary. A l l informants signed statements o f in formed consent (Appendix C ) and each was assured that all in format ion w o u l d be kept confidential . T o maintain informant anonymity transcripts and computer files were coded numerical ly and pseudonyms were used in place o f informants ' real names. A p p r o v a l f o r the study was obtained from the Universi ty o f Br i t i sh Columbia Behavioural Sciences Screening Commit tee F o r Research and Other Studies Invo lv ing H u m a n Subjects, as we l l as the Ethics Commi t tee F o r H u m a n Exper imentat ion at St. Paul 's Hospi ta l (Append ix D ) . 3.4.3. Data Collection A l l data were collected by the pr imary researcher. Appropr ia te undergraduate and graduate level courses, relevant l i terature, and pi lot interviews prov ided the guidance and experience necessary to collect qualitative data. A pi lot in terv iew was conducted to a l low others to prov ide feedback on my interviewing technique and skills, and t o test proposed in terv iew questions. In terv iew techniques described by Spradley (1979) to get the informants ta lk ing were used to conduct interviews. These included el ici t ing in fo rmat ion by asking 73 D E S I G N A N D M E T H O D S descript ive questions, expanding the length o f the questions to expand the length o f the response and asking fo r the use and not the meaning o f the informants ' terms. The semi-structured in terv iew guide developed fo r the first set o f interviews is found in Append ix E. Over the course o f the study, I conducted 17 face-to-face semi-structured in-depth interv iews w i t h 14 informants at sites that were convenient t o them. Twe lve telephone interv iews were also conducted. The term semi-structured means that the in terv iew guide contained a list o f top ic areas or general open-ended questions wh ich needed t o be addressed dur ing the interv iew; however, some degree o f flexibility was maintained by adapting the w o r d i n g and sequence o f interview questions to each informant. I n all cases the informants were encouraged to tel l their stories in their o w n way, w i t h their o w n words and h o w they chose t o frame and structure their responses was respected. Since the issues important t o the informants were u n k n o w n at the beginning o f the study, the first seven interviews involved general discussions about the informants ' "cholesterol stories," as we l l as their experiences w i t h and perspectives o f the cholesterol-lower ing dietary change process. T o explore personal and environmental factors that inf luenced the cholesterol- lowering dietary change process, informants were encouraged to discuss factors that made i t easy or hard fo r them to accomplish dietary change. The examinat ion o f possible faci l i tators and inhibitors, as we l l as questions about h o w change was accomplished was used to reveal the strategies informants used to br ing about change. F o l l o w i n g prel iminary analysis, the interview guide was revised fo r each subsequent in terv iew so the questions reflected the stage o f analysis and corresponded to the emerging categories and theory. 74 D E S I G N A N D M E T H O D S Conduct ing analysis pr ior to further data col lect ion al lowed me to use each round o f interv iews t o con f i rm or disprove m y interpretations o f the data and fur ther substantiate the relationships w h i c h had emerged. Four more interviews were conducted t o elicit more in format ion about the dietary change process in general, and more specifically about emerging categories. T w o more cycles o f analysis and further data col lect ion t o o k place before all 14 informants were interviewed. Dur ing these cycles, second in-depth interv iews were conducted w i t h 3 informants (Bruce, Janice, Richard). Second interviews a l lowed me to cont inue explor ing informants ' experiences w i t h making changes to l ower their b lood cholesterol levels, as we l l as to review the findings or interpretations o f the in format ion obtained previously to ensure the analysis t ru ly represented their experiences (this process is referred to as member checking). Later interviews were more structured to elicit more specific in format ion about the emergent categories (see Appendix F fo r an example). I n depth- interviews ranged in length from 45 to 90 minutes. I recorded the face-to-face interviews on tape and produced a complete verbat im transcript f o r each. Several types o f fieldnotes were generated fo l low ing each interview. Descr ipt ive fieldnotes recorded m y observations from interviews wh ich were not recorded on the tape (e.g. body language, facial expressions). Ref lexive fieldnotes included comments and ideas about the interviews, as we l l as m y ini t ia l impressions and interpretations o f what was said. They also contained comments about myself, such as h o w I felt about the research process and h o w I thought that may affect the data col lect ion or analysis process, as we l l as my thoughts regarding h o w I may influence wha t is said dur ing or interpreted from the interviews. 75 D E S I G N A N D M E T H O D S F o l l o w i n g extensive analysis and theory development, the informants were supplied w i t h a fou r page summary o f the findings as we l l as a model designed t o capture the pr imary concepts o f the theory (Appendix G ) . As part o f the hermeneutic dialectic research process described above, the purpose o f this stage o f data col lect ion was to ensure that indiv idual construct ions were depicted as accurately as possible and to confront the informants w i t h the construct ions o f others. Telephone interviews were then conducted w i t h 12 o f the informants in order to ascertain the fo l low ing : 1) whether the explanation was clear enough fo r them to understand the findings, 2 ) wh ich part o f the model was similar to their experiences, 3) w h i c h part o f the model was different from their experiences, and 4 ) whether the mode l omi t ted aspects o f their experiences. These interviews ranged in length from 15 t o 40 minutes. A l t h o u g h not tape recorded, applicable comments were noted dur ing the interviews. Telephone interviews were not conducted w i t h t w o informants because they were unavailable at that t ime (one was w o r k i n g out o f t o w n fo r a year and the other was very busy). Nonetheless, feedback was obtained from bo th o f these informants dur ing a second, face-to-face in terv iew at an earlier t ime. I n addi t ion to the interviews, data col lect ion also consisted o f obtaining some biographical characteristics from the informants t o ensure that the sample g roup cou ld be w e l l defined and described. T o consistently record this in format ion, an informant questionnaire was developed and given to each informant pr ior to his/her first in terv iew (Append ix H ) . I respected the rights o f informants t o not provide in format ion i f they chose no t t o ; hence some in format ion, such as education completed is u n k n o w n fo r some individuals. Other fieldnotes maintained dur ing the research process included academic notes and methodologica l notes. 76 D E S I G N A N D M E T H O D S Academic notes contained ideas I obtained from the l i terature as the research progressed. Methodo log ica l notes documented decisions made dur ing the research process and changes made t o the proposed research question o r process. Fo r example, these notes included answers to the fo l l ow ing questions: "Wha t direct ion am I go ing in?" "Shou ld I go in a different d i rect ion?" "Shou ld I be doing something dif ferent?" " W h y am I do ing something dif ferent than wha t I said I was go ing t o do?" 3.4.4. Data Analysis D a t a col lect ion, data analysis and report wr i t i ng were conducted simultaneously th roughout the research process. The general principle o f constant compar ison (Glaser and Strauss, 1967), open coding procedures (Strauss and Corb in , 1990), de-contextual izat ion and re-contextual izat ion methods (Tesch, 1990), display and matr ix analysis (Mi les and Huberman, 1994), as we l l as dimensional analysis (Schatzman, 1991 ; K o o l s et al., 1996) guided data analysis and interpretation. T w o stages o f analysis are c o m m o n t o these techniques. A th i rd stage, construct ing a conceptual model and generating a theoret ical framework, is discussed later on. 3.4.4.1. Open Coding and Data Interpretation I n the f irst stage, the data were broken d o w n or reduced in to manageable segments by using open coding o r de-contextual ization procedures and methods. The segments were then compared, conceptual ized and organized fo r the purpose o f developing categories o r themes that ref lected key issues and events. This stage is also referred to as the "da ta organiz ing" phase (Tesch, 1990). 77 D E S I G N A N D M E T H O D S The second stage o f data analysis involved put t ing the data back together in new ways by mak ing connections between categories to identi fy relationships among the themes and concepts and br ing meaning and insight to the data. This stage is o f ten thought o f as the "da ta in terpretat ion" phase (Tesch, 1990). A l though not aware o f i t at the t ime, I proceeded in this stage by "d imensional iz ing" the data as described by Schatzman (1991) rather than using the axial cod ing techniques outl ined by Strauss and Corb in (1990). That is, dimensions o f experience were coded w i thou t regard to whether they appeared as structures o r processes, context or condi t ion. Instead, I simply identif ied experiences that seemed t o answer the question: " W h a t all is involved here?" A l t h o u g h the data organizing and interpretat ion phases were described as separate stages above, they were intellectually intertwined and happened simultaneously. The ATLASU computer software program was used to organize and manage data in these t w o stages. This p rogram faci l i tated div id ing the relevant text into meaningful segments and sort ing these segments in to groups whi le retaining their contextual meaning (Tesch, 1990). T o begin coding, I carefully examined the data i n search o f features and patterns w h i c h were subsequently labeled. I n most cases, the terms chosen as "codes" were the informants ' words ; otherwise k n o w n as "nat ive" or " f o l k terms." This strategy helped keep the analysis grounded in the data. A benefit o f ATLASti is that the list o f codes was visible at all t imes, faci l i tat ing their comparison fo r relevance in subsequent transcripts. Once several transcripts were b roken in to segments and coded, the code list was examined and related ideas were grouped together. Label ing these groups or "categories" wh ich dealt w i t h related concepts moved the analysis to a higher theoretical level (Strauss and Corb in , 1990). Subsequent 78 D E S I G N A N D M E T H O D S t ranscript segments and codes were then compared to the emerging categories, and new segments that d id not " f i t " indicated the need fo r new categories or suggested that established categories required revision. Consequently, data analysis involved many cycles o f generating and revising categories as new informat ion emerged f r o m the data. A s the data were pu t back together in to categories, several " co re " categories emerged wh ich seemed to account fo r a major po r t i on o f the var iat ion between informants (Glaser, 1978; Strauss and Corb in , 1990). A s codes and categories emerged f r o m the data in the f irst t w o stages o f analysis, an integral part o f the research process was wr i t i ng analytical memos to explain categories and the relationships between them. I t has been said that w r i t i ng is a w a y o f k n o w i n g or a method o f discovery and analysis, and through wr i t ing , new aspects o f the top ic are discovered (Richardson, 1994). M i les and Huberman (1994) also p romote that the act o f w r i t i n g as a focusing and forc ing device that guides further analysis. T o them " w r i t i n g is th ink ing, not the report o f though t " (p. 89). Indeed, I found that wr i t i ng about w h y an incident was tagged w i t h a specific code and what was meant by a particular code faci l i tated the th ink ing process and raised issues that needed to be explored in more depth dur ing subsequent interviews. The memos also helped me to clarify ideas and connect the results as a meaningful who le , thereby contr ibut ing to the development o f a theoretical f ramework. The substance o f these memos was always based o n and grounded in the data. B y cont inuously go ing back t o earlier memos and/or the transcripts, I ensured that the memos were always t rue to the data. Ideas not grounded in the data were always identif ied as " theoret ica l " memos. Aga in , ATLASu was used to w r i t e these memos and l ink them to the relevant data. 79 D E S I G N A N D M E T H O D S 3.4.4.2. Developing A Model and Theoretical Framework The th i rd stage o f analysis and interpretat ion involved the construct ion o f a conceptual model that depicted the relationships between the major categories and themes. Acco rd ing to Earp and Ennet t (1991) , a conceptual model is " a diagram o f proposed causal l inkages among a set o f concepts believed to be related to a specific ... p rob lem" (p. 163). Fur thermore, the purpose o f a conceptual model is not to incorporate all factors correlated w i t h an endpoint o f interest, but t o show only part o f the causal web. That is, conceptual models call at tent ion to specific factors and the interact ion among them w i th in specific contexts. I n addi t ion to the guidelines set out by Earp and Ennett (1991) and Radnofsky (1996) , mode l development was assisted by t w o other research tools: display and matr ix analysis (Mi les and Huberman, 1994) and dimensional analysis (Schatzman, 1991 ; K o o l s et al., 1996). Ar rang ing data into displays and matrices helped br ing together i tems that were connected and helped me visualize conceptually related data. The displays and matrices also emphasized the similarities and differences w i th in and between concepts. Once the main concepts o f the data were apparent, dimensional analysis was used to organize them into a theoret ical story. A l t h o u g h dimensional analysis was developed several decades ago, its existence has only recently been repor ted in the literature. Thus, before explaining h o w data were analyzed using this method, a br ie f in t roduct ion to this method is provided. Dimensional analysis is an analytical f ramework developed by Schatzman at the Univers i ty o f Cal i fornia as an alternate methodological approach and model f o r generating grounded theory. This f ramework is concerned w i t h " the analysis integral t o interpretat ion i t s e l f w h i c h is essential fo r understanding particular problematic experiences. I t helps 80 D E S I G N A N D M E T H O D S address the question " W h a t all is involved here?" w i t h the aim o f analysis being to discover the meanings o f interactions observed in situations. The outcome o f this alternative method fo r generating grounded theory is an explanatory matr ix w h i c h "dif ferentiates the innate characteristics o f identi f ied dimensions into various conceptual components, such as context, condit ions, processes, o r consequences" (Koo ls et al., 1996, p. 318). Acco rd ing to Schatzman (1991) : an explanation ... tells a story about the relations among things or people and events. T o tel l a complex story, one must (a) designate objects and events, (b) state o r imply some o f their dimensions and properties (i.e., their attr ibutes), (c) prov ide some context fo r these, (d) indicate a condi t ion or t w o fo r whatever act ion or interact ion is selected to be central t o the story, and (e) point to , o r imply, one or more consequences. T o do all this, one needs at least one perspective to select items for the story, create their relative salience, and sequence them (p. 308). I n other words , perspective gives "theoret ical and explanatory f o r m to a story that w o u l d otherwise be regarded, at best, as fine descr ipt ion" (Schatzman, 1991, p. 313) . Thus, the "explanatory mat r i x " provides structure and gives direct ion fo r examining a problematic phenomenon's parts, attributes, interconnections, context, processes, and impl icat ions. A f te r extensive examination and interpretat ion o f the data, dimensional analysis was used to organize the main concepts into a theoretical story and to test their explanatory p o w e r by searching fo r alternative explanations. A s prescribed by Schatzman (1991) , each dimension (i.e. code or concept) was g i v e n — " m o m e n t a r i l y at l e a s t " — t h e conceptual oppor tun i ty o f being elevated to the status o f perspective where it then governs the value and status o f other dimensions. Aga in the most important process I engaged in at this stage was wr i t i ng . In terpretat ion o f the data at this stage was a process o f w r i t i n g memos w h i c h explained the major themes, checking earlier memos and transcripts to ensure these memos were grounded 81 D E S I G N A N D M E T H O D S in the data, w r i t i n g more memos, checking w i t h informants that the themes were va l id , w r i t i n g more memos, etc. (Chapman, unpublished dissertation proposal, 1988). W r i t i n g mul t ip le memos o f the study results enabled me " t o coalesce and synthesize these results in to a meaningful ... theoret ical f ramework" (Achterberg, 1988, p. 247). This process cont inued unt i l fur ther checking w i t h transcripts and new informants d id not y ie ld new in format ion. Once i t became clear wh ich dimension fit best as the central dimension or perspective, i t was used t o determine the salience o f other dimensions and organize their placement as either context, condit ions, processes, or consequences and i t contro l led the l ine o f inquiry and reasoning. A t this point, a model was developed in order to make sense o f the emerging theoret ical f ramework . Construct ing a model was a lengthy, mult i -step process. The f irst step invo lved w r i t i n g theoretical memos wh ich examined the relationships between the central dimension and other salient dimensions. Nex t , a simple diagram was created to represent the content o f the memos. The second step involved meeting w i t h m y thesis supervisor to rev iew these memos and the diagram. W e discussed the strengths and weaknesses o f h o w the emerging theoretical f ramework was presented and brainstormed about other ways i t cou ld be represented. M o r e memos were wr i t ten t o sort out what was go ing o n in the data and force me t o quest ion assumptions, relationships and connections. A second meet ing w i t h m y thesis supervisor to brainstorm and draw pictures yielded a model w e thought depicted the central concepts o f the theoretical framework in a meaningful way. A f te r w r i t i n g a summary o f the main concepts in the model , the th i rd step invo lved meet ing w i t h m y thesis committee to review the model and summary. This step was a good test o f the emerging theoretical framework because the thesis commit tee members had had 82 D E S I G N A N D M E T H O D S l i t t le exposure to the data throughout the research process. They recognized the weaknesses o f the mode l and suggested where improvements could be made. F o l l o w i n g fur ther examinat ion o f the data and more memo wr i t ing , another meeting w i t h m y thesis supervisor was held i n w h i c h w e considered numerous ideas and drew pictures that conveyed the essence o f the emerging theoretical f ramework unt i l a meaningful and visually clear model was developed. A l l t o ld , the process o f developing a conceptual model moved the analysis to a higher theoret ical level and gave me a better understanding o f the data because the process forced me t o use alternative modes o f th inking. A s assured by Earp and Ennet t (1991) , the process helped w i t h summarizing and integrating the central categories and themes, def in ing concepts, p rov id ing explanations fo r causal linkages, and generating a theoret ical f r amework o f the process o f dietary change. Finally, bo th the model and a br ie f explanation o f the concepts encompassed in the model were mailed to the informants in order to obtain their feedback regarding whether their experiences were accurately reflected in the analysis. They were also asked about their reactions t o the model . This feedback supported the interpretat ions o f the data, indicated where some gaps were in the theory, and helped sol idi fy the constructed theoret ical f ramework . M i n o r changes were made to the model to accommodate the feedback obtained from the informants. 3.5. Cr i te r ia fo r Assessing Research Qual i ty Research conducted from a constructivist paradigm using qual i tat ive methods is frequently v iewed negatively because i t fails to comply w i t h the cr i ter ia o f r igor associated w i t h the convent ional scientific paradigm. That is, skeptics of ten quest ion the t ru th value 83 D E S I G N A N D M E T H O D S ( internal val id i ty) , applicabil i ty (external val id i ty o r generalizabil i ty), consistency (rel iabi l i ty or reproducib i l i ty) , and neutral i ty (object iv i ty) o f qualitative research (L inco ln and Guba, 1986). H o w e v e r , i t is important t o realize that these criteria consist o f rhetor ic inherently part o f the scientific paradigm wh ich relies on quantitative methods. A s stated by Lein inger (1992) "us ing quanti tat ive cr i ter ia fo r qualitative analysis refutes the very purposes o f the qualitat ive paradigm and its phi losophy" (p. 402). Consequently, the quali ty o f research conducted using qual i tat ive methods should be judged by more appropriate c r i t e r i a — t h e t rustworthiness o f the research, the researcher's theoretical sensitivity, and the usefulness o f the f indings. 3.5.1. Establishing Trustworthiness Whi le there are no firmly agreed upon criteria f o r j udg ing construct iv ist research, this area has received much attention in the literature. O f this discourse, the cr i ter ia proposed by Guba and L inco ln are the most prominent (L inco ln and Guba, 1986; Guba and L inco ln , 1994; L inco ln , 1995). They suggest four criteria wh ich methodological ly parallel the cr i ter ia o f rigour set fo r th by the scientific paradigm. Consequently, research i n the construct iv ist paradigm can be judged according to i t ' s trustworthiness, whereby trustworthiness is determined by the fo l low ing criteria: credibil i ty, transferabil i ty, dependabil i ty, and conf i rmabi l i ty. 3.5.1.1. Credibility A s an analog to internal val idi ty, credibility refers to the " t ruthfu lness" o f the findings. Marsha l l and Rossman (1989) report that the goal o f this construct " is to demonstrate that the inqui ry was conducted in such a manner as to ensure that the subject was accurately identi f ied and described" (p. 145). I engaged in various activities t o increase the probabi l i ty o f h igh 84 D E S I G N A N D M E T H O D S credibi l i ty, inc luding prolonged contact w i t h the informants, persistent explorat ion fo r signif icant concepts, and the use o f mult iple sources o f data. Ano ther w a y I ensured credibi l i ty was to conduct "member checks" by solicit ing the informants ' reactions to the findings. A l ternat ing between data col lect ion and analysis a l lowed informants t o rev iew the findings and interpretations dur ing subsequent interviews and prov ide feedback w i t h respect to the emerging categories, themes, and conclusions. I made sure every in formant had the oppor tun i ty t o assess whether their experiences were t ru ly reflected in the analysis. Credibi l i ty was also enhanced by keeping professional peers (such as the thesis supervisor and commit tee) in formed w i t h regards to the progress o f the research and i ts findings. This "peer debr ief ing" helps to "keep the inquirer honest" (L inco ln and Guba, 1986, p. 77) . H i g h credibi l i ty was also achieved by actively searching fo r negative instances to relate to and incorporate in to the developing theory. Finally, in the results section all concepts and theoret ical formulat ions are supported w i t h actual data. 3.5.1.2. Transferability I n terms o f the applicabil i ty o f the findings to another sett ing o r g roup o f people, transferability is used as an analog to external validity. Since i t is assumed that human actions and understandings cannot be separated from their context, being able t o generalize findings to another setting is not a major goal w i th in the constructivist paradigm or w h e n using qual i tat ive methods (Chapman and Maclean, 1990; L inco ln and Guba, 1985). A l t h o u g h the burden o f demonstrat ing transferabil ity rests more w i t h the investigators w h o w o u l d make that transfer than w i t h the original investigator, their abil i ty t o judge whether the findings can be applied to others depends on an accurate and complete " th i ck " descript ion o f the sample 85 D E S I G N A N D M E T H O D S populat ion (Marshal l and Rossman. 1989). Thus, t o maximize the transferabi l i ty o f the f indings Chapman and Maclean suggest the researcher "be explici t about h o w data were col lected, the condit ions under wh ich they were collected and w h o they were col lected f r o m " (p. 133). F o r this study, in format ion on sample selection, data col lect ion, and data analysis ( inc luding the methods fo r concept and theory development) is found in this chapter. A detailed descript ion o f the sample is provided in the next chapter. 3.5.1.3. Dependability Because the constructivist paradigm assumes mult ip le realities that are always changing, the findings o f this type o f study cannot be replicated. Hence, as an analog to rel iabi l i ty, dependability is used to judge the trustworthiness o f the research. T o convey dependabil i ty I accounted fo r changing condit ions, as we l l as changes in the research design, by keeping tho rough notes that recorded each research design decision and the rationale behind i t (Marshal l and Rossman, 1989). These records, referred to as methodologica l notes above, enable others to inspect o r audit the research process i n terms o f the reasoning behind the procedures and protocols ut i l ized (Rodgers and Cowles, 1993). 3.5.1.4. Confirmability Confirmability o f the findings—an analog to ob jec t i v i t y—he lps t o determine that the findings are ref lect ive o f the informants and the inquiry itself, rather than a produc t o f m y o w n biases or prejudice. W o r t h y constructivist researchers k n o w that their o w n formulat ions have no part icular pr ivi lege in this type o f study save that they are the only person w h o has moved extensively between informants (Guba and L inco ln , 1989). I n this study, I had the benefit o f having heard a more complete set o f constructions than anyone else was l ikely t o have heard; 86 D E S I G N A N D M E T H O D S thus, m y construct ion o f what the informants experienced is l ikely to be one o f the most in fo rmed and sophisticated, at least t o w a r d the end o f the process. I n response to concerns that the subjectivity o f the researcher w i l l shape the research, I f o l l owed the controls fo r bias presented by Marshal l and Rossman (1989) . First , ref lexive fieldnotes prov ided a f o r u m fo r me to deal w i t h biases, frustrations, and personal theories that were separate from the data. Second, I control led fo r bias by: checking and rechecking the data, searching fo r negative cases, testing possible r ival hypotheses, and asking questions o f the data. A th i rd contro l fo r bias involved having the thesis supervisor and commit tee cr i t ical ly quest ion the analysis and interpretation. Finally, the var ious notes and memos generated dur ing the research process are available fo r formal rev iew and prov ide a means fo r t rack ing the evolv ing analysis and moni tor ing personal responses, and fo r audi t ing the research product to determine whether the findings are reasonable and " f i t " the data (L inco ln and Guba, 1986; Rodgers and Cowles, 1993). Conf i rmabi l i ty also relies on the neutral i ty o f the researcher. B y adopt ing a stance o f neutral i ty, the researcher does not set out to prove a part icular perspective or manipulate data t o arr ive at predisposed truths (Patton, 1980). I maintained neutral i ty by becoming aware o f and dealing w i t h biases (as outl ined above), as we l l as by not advocat ing personal agendas and remaining non-judgmental t oward study informants. T o achieve neutral i ty wh i le finding out about the informants ' experiences, I kept my opinions about nut r i t ion and dietary change to myself. The informants were informed that I was w o r k i n g t o w a r d a Mas te r ' s i n N u t r i t i o n ; however, the extent o f m y nut r i t ion knowledge was not revealed and w h e n asked nu t r i t ion-related question, I pretended to "no t k n o w " the answer and suggested the in formant check 87 D E S I G N A N D M E T H O D S w i t h a diet i t ian at the clinic. Neutra l i ty was also maintained by suspending (o r at least, not expressing) judgment about the informants' behaviours. I emphasized that I was interested in the process o f change and never judged their abil i ty t o achieve change. Demonst ra t ing a genuine interest in their experiences and suspending judgment also helped elicit cooperat ion, trust, openness and acceptance f r o m the informants (Spradley, 1979). 3.5.2. Theoretical Sensitivity A s the researcher is the " inst rument" o f data col lect ion and analysis, the credibi l i ty and dependabil i ty o f the f indings rely on the methodological ski l l , sensitivity and integr i ty o f the researcher, in terms o f discipline, knowledge, training, practice, creat iv i ty and hard w o r k (Pat ton, 1980), Theoretical sensitivity, wh i ch is an important creative aspect o f grounded theory, refers t o the attr ibute o f having insight into the area o f research, the abi l i ty t o give meaning t o data, and the capacity t o recognize and understand what is relevant (Glaser and Strauss, 1967; Strauss and Corbin, 1990). Var ious personal experiences contr ibuted t o the development o f m y theoretical sensitivity. First, a grounding in the health p romot ion and behaviour change l i terature sensitized me to what is go ing on in this f ield. Second, professional experience teaching cholesterol - lower ing nutr i t ion education programs facil i tated an understanding o f h o w dietary change is accomplished. This knowledge helped me understand the events and actions the informants described, and to do so more quickly than i f I had not had this background. Final ly, personal experience w i t h dietary change efforts prov ided a basis f o r mak ing comparisons that in tu rn stimulated the generation o f potential ly relevant concepts and their relationships. Strauss and Corb in (1990) also suggest that previous research, such as m y 88 D E S I G N A N D M E T H O D S project o n young w o m e n ' s experiences w i t h and concerns about f o o d (unpubl ished), becomes a useful aspect o f one's personal experience. M y theoretical sensitivity was also developed throughout the research process as interact ion w i t h the data and data analysis increased my insight and understanding. That is, theoret ical sensitivity came from asking questions about the data, mak ing comparisons, th ink ing about what was emerging, making hypotheses, and developing theoretical frameworks about the concepts and their relationships. This enhanced insight and understanding directed me to look more closely at the data, give meaning t o w o r d s that seemed previously not to have meaning, and look fo r situations that might explain what was happening in the data. Thus, i t is obvious w h y i t is so important t o interweave data col lect ion w i t h data ana lys is—each feeds in to the other (Strauss and Corbin, 1990). 3.5.3. Usefulness of Findings I n addi t ion to judg ing procedural and methodological quali ty, a study should be judged according to the usefulness o f the findings. That is, more attent ion should be g iven to " the use o f qual i tat ive research findings to understand and improve human condi t ions" (Leininger, 1992, p. 409) . Recal l that research stemming from the construct ivist paradigm represents the cont inuing search fo r ever more informed and sophisticated construct ions so that understanding o f the experience or f o r m o f act ion under study can be cont inuously revised and enriched. F r o m this perspective, i t is logical that an indicator o f a study's usefulness is whether its findings serve to generate new insights. Another indicator o f a study's usefulness is the appl icat ion o f its findings in a practical setting. I t is impor tant to remember that 89 D E S I G N A N D M E T H O D S quali tat ive findings can be used immediately to improve a situation w i thou t having to undergo repl icat ion or be subjected to quantitative testing (Leininger, 1992). 90 R E S U L T S CHAPTER 4: RESULTS This chapter presents a description o f the informants and examines their experiences w i t h the process o f l ip id- lower ing dietary change. A f te r discussing the characteristics o f hyperl ip idemia as perceived by the informants, informants ' v iews o f healthy eating are presented, and h o w they established healthy eating behaviours is described. Nex t , the conceptual model constructed to understand hyperl ipidemic adults' experiences w i t h making dietary changes is explained. 4.1. Study Informants A descript ion o f the study informants is presented in Table 4 . 1 . The informants ranged f r o m 37 to 69 years o f age w i t h a mean age o f 52. Three o f the w o m e n were single and l ived on their o w n . The other four w o m e n were married and t w o had young chi ldren l iv ing at home. M a r r i e d w o m e n were responsible fo r feeding their fami ly o r shared this responsibi l i ty w i t h their husbands. A l l but one o f the men were married or l ived w i t h a partner. O f the marr ied men, one had young children at home, whi le t w o had one or more adult chi ldren at home. Some marr ied men shared feeding responsibilities w i t h their wives. T w o w o m e n were ret i red at the t ime interviews were conducted. Finally, most informants were bo rn in Canada, and a l though their cultural heritage varied, a Br i t ish heritage was the most prominent. The l ip id characteristics o f informants are presented in Table 4.2. Three informants were diagnosed one year or less pr ior t o being interviewed. Five informants were diagnosed less than 5 years before being interviewed. Finally, 6 informants were diagnosed more than 5 years before the study. Seven informants were tak ing l ip id- lower ing medicat ions dur ing the 91 R E S U L T S Table 4.1 Demographic Profiles of Informants INFORMANT A G E MARITAL STATUS LIVING SITUATION EDUCATION OCCUPATION COUNTRY OF ORIGIN CULTURAL HERITAGE Anne1 56 married with husband High School Accounting Clerk Jamaica Negro2 Bruce 44 married with wife and 3 children (5,12,15) College Actor Canada British Claudia 62 single on own High School Retired Secretary Canada Romanian Doug 50 married with wife and 2 sons (20, 22) College (2 years) Sales Canada British Grace 69 single on own University (I year) Retired Registered Nurse Canada Scottish/British Janice 57 married with husband University (graduate level) Retired Teacher Canada British/Italian/ Austrian Kevin 37 common-law with girlfriend College Colourist (Film Industry) Canada Japanese Matt 46 married with wife unknown Electronic Consultant Canada British Nancy 42 married with husband and son (9) College Administrative Support-Clerical (part-time) Canada Scottish/ Ukrainian Oliver 62 married with wife and son (25) University (graduate level) Financial "Intake" Worker (Social Work) USA Polish Richard 50 single (separated) on own Grade 12 Market Manager Canada German/Scottish Steve 61 married with wife University Retired Engineer / Entrepreneur Canada British/Swedish-Norwegian Tracy 38 married with husband and 2 children (6, 8) University (2 years) Homemaker Canada Japanese Victoria 57 single (divorced) on own unknown Secretary England British 1 Pseudonyms substituted for actual names. 2 Cultural heritage is reported as indicated by informants. 92 R E S U L T S Table 4.2 Lipid Characteristics of Informants INFORMANT YEAR OF DIAGNOSIS FIRST VISIT TO LIPID CLINIC LIPID CLINIC DIAGNOSIS CHOLESTEROL MEDICATIONS B M I FAMILY HISTORY OTHER RISK FACTORS Anne 1988 Oct 1992 polygenic hypercholesterolemia pravastatin 22.7 not sure (mother had a stroke) Bruce 1993 Feb 1994 hyperlipidemia/ hypertriglyceridemia niacin 24.0 father, brother, uncles former smoker Claudia 1985 Feb 1988 hyperlipidemia niacin 21.9 mother, sister, uncles, aunt, grandmother high blood pressure Doug 1993 1994 probable genetic hyperlipidemia / hypercholesterolemia lipidil 31.7 mother, aunts, uncles Grace 1986 Mar 1986 unknown no (mevacor in past) 21.0 no Janice 1986 May 1994 hypertriglyceridemia no 25.6 mother, brother, grand-father high blood pressure Kevin 1992 1996 probable familial combined dishyperlipidemia lipidil 28.3 brother, maybe mother former smoker Matt Jan 1996 Apr 1996 probable hyperlipidemia (congenital misrooted circumflex artery) no 29.7 father, father-in-law Nancy 1992 (?) Sep 1995 familial combined hyperlipidemia / familial hypercholesterolemia no 32.5 paternal grandfather, mother, sister former smoker Oliver 1988 (?) Apr 1989 hyperdislipidemia no (mevacor in past) 30.0 mother Richard Mar 1995 Apr 1995 dilated cardiomyopathy/ hyperlipidemia pravachol, lipidil, lisinopril 23.4 mother, brother smoker Steve 1984 Nov 1984 hypertriglyceridemia/ low HDL cholesterol gemfibrozl 24.3 2 brothers, maybe father Tracy Apr 1995 May 1995 marked hypertriglyce-ridemia / polygenic hyperlipidemia no i 31.3 father, aunts, uncles, sister former smoker Victoria 1994 Aug 1994 mixed hyperlipidemia (hypothyroid) no 34.4 no former smoker 9 3 R E S U L T S study. Interest ingly, bo th informants tak ing niacin d id not consider themselves t o be o n medications. Regardless, all informants on medicat ion were t ry ing to change their diet in order t o lower their b lood l ip id levels. T o further describe the sample populat ion, Table 4.2 also presents each informants ' r isk factor prof i le wh ich includes B M I , fami ly history o f hyper l ip idemia and/or heart disease and other r isk factors. 4.2. Characteristics of Having High Blood Lipid Levels In formants ' understandings o f having h igh b lood l ip id levels included several perceptions. First, informants knew that they were "a t r isk" fo r coronary heart disease ( C H D ) and/or strokes, but of ten perceived being "at r isk" as an "abstract" concept because they d id not experience symptoms or " feel sick." .. .honestly t o me r ight n o w i t ' s very abstract. I t ' s a number. I t doesn' t have very much direct correlat ion to me, to any physical effect I have. I d o n ' t have any h igh b lood pressure problems or anything currently. So all i t is t o me r ight n o w is a number that represents some k ind o f a potential r isk level. ( M a t t ) Second, informants recognized that there were multiple behaviours related to r i s k — d i e t , physical act iv i ty, smoking, and alcohol in take—because, i f appropriate, the doctors encouraged them t o modi fy all o f them on order t o reduce their r isk f o r C H D . Th i rd , informants associated uncertainty and interindividual-variability w i t h the potent ia l outcomes o f mak ing changes. They perceived there was uncertainty because their b lood l ip id levels f luctuated i n response to a variety o f factors and there were no overt signs o f changes to their b lood l ip id levels. Fo r example, Claudia had no idea w h y her cholesterol had gone up and could not figure out what she ate that w o u l d have caused i t t o go up. Similarly, B ruce said his cholesterol "m igh t have spiked up ... o r i t might have spiked d o w n , " he d id not k n o w " h o w that 's go ing t o g o . " Grace's comment typif ies the uncertainty experienced by the informants: 94 R E S U L T S Before I was jus t frantic about being very careful, and i t seemed l ike i t d idn ' t make any difference even at- W h e n I went fo r m y yearly check-up I was S T I L L F f l G H w i t h everything I ' d done. A n d I haven't been N E A R L Y as strict and i t ' s G O I N G D O W N . ... So I don ' t know. (Grace) 3 Overal l , they recognized that there was also no guarantee that behavioural changes w o u l d result in desirable outcomes. Also, in most cases they knew that the potent ia l ly negative consequences o f having h igh b lood l ip id levels were not immediate and w o u l d not be experienced fo r many years, i f at all. W e l l i t ' s sort o f much more l ike the- I t ' s not l ike (when I had) the ulcer. That was sure and certain: " I f you eat this, you ' re go ing to be in pa in . " Tra- la. Instant- W e l l 20 minutes sort o f th ing "Bang , you ' re go ing to suffer f o r i t . " Fine I ' l l not eat i t thank-you very much ... B u t these 10, 20, 30 years d o w n l ine deallies are harder to th ink about. (V ic tor ia) I n terms o f inter individual variabil i ty, some informants recognized that what const i tuted enough change fo r one person d id not result in desirable outcomes fo r someone else. Fo r example: I jus t hope i t doesn't go up again. I ' l l just watch the who le year and see i f the cont inued diet is okay. Because I k n o w m y mother had h igh- A n d she had to cut out a lot. She had lost a lo t o f weight, and she cut out everything and i t d idn ' t seem to go d o w n this much, but everybody's different. (Claudia) Four th , informants perceived that they were in charge o f mak ing their o w n decisions and choices about their lifestyles. They chose what to focus on in terms o f mak ing changes (e.g., mak ing dietary modif icat ions, qui t t ing smoking, exercising more, tak ing drugs), whether to even make changes in the first place, and what changes were or were not acceptable t o them. B U T I D I D N ' T R E A L L Y want to take any drugs at all, per iod. So I ... w o r k e d i t out that what I w o u l d do is I w o u l d — w i t h m y doctor and the nutr i t ionists h e r e — I t r ied to f ind some way o f not having to do that where I cou ld lower the b lood cholesterol th rough exercise and diet. (Bruce) 3 Capitals were used during transcription to denote informants' emphasis on certain words. 95 R E S U L T S I stay away from cheese. I used to dr ink 2 % mi lk , I ' ve I switched to 1 % . I ' m not about t o go to skim. (Richard) Wh i le several l ifestyle behaviours were associated w i t h being at risk f o r C H D , the emphasis o f this study is the eating behaviours associated w i t h this risk. Therefore, even though informants init iated other lifestyle changes to reduce their risk f o r C H D , the findings presented here concentrate pr imari ly on the dietary change process. Other l i festyle behaviours are discussed as they relate t o eating behaviours. 4.3. Healthy Eating W h e n informants discussed the changes they had made to their eating behaviours, many said they had to " w a t c h " or "be careful" about what they ate. That is, they d id not " just eat anyth ing," they control led their intake and did not give into cravings o r temptat ions all the t ime, they had to find out what was in foods, and they had to " t h i n k " and make decisions about wha t t o eat and not eat. A t the same t ime, informants were not "over l y carefu l " about everything they ate. For example, Grace said she was "qui te careful, but no t str ict ly careful . " Be ing "reasonable" was another aspect o f healthy eating because they d id no t want t o be obsessed w i t h f o o d and stil l wanted to enjoy life. The interviews included questions about what factors informants considered when deciding what t o eat or not eat and h o w they were making changes t o the foods they ate in order t o lower their b lood l ip id levels. The descriptions and explanations that ensued are presented be low in t w o sections: def ining healthy eating, and establishing healthy eating behaviours. 4.3.1. Defining Healthy Eating W h e n the informants discussed the changes they were making, they ta lked about the 96 R E S U L T S types o f foods they ate. Consequently, the first part o f the discussion be low examines what foods the informants thought were appropriate and inappropriate. The second part o f the discussion examines h o w the informants decided what was appropriate and inappropriate. 4.3.1.1. Food Appropriateness F o o d appropriateness refers to the informants ' beliefs that some foods are healthy, wh i le others are unhealthy. A l l o f the informants made a dist inct ion between healthy foods they should eat (appropriate foods) and unhealthy foods they should not eat ( inappropriate foods) . Appropr ia te foods, wh ich included things l ike f rui ts and vegetables, and homemade foods, were also described as "sensible foods," " g o o d stuff," "p roper f o o d , " " th ings that are l o w - f a t " and " w h a t ' s good fo r me." Inappropriate foods, wh ich included things l ike red meat, processed, and packaged or convenience foods, were described as " the w r o n g th ings," " the bad stuff ," " r i ch foods, " "wha t you can' t have," and " the unnecessary stuff ." Even though the informants talked about healthy or g o o d foods and unhealthy or bad foods, they also evaluated foods w i th in the context o f their overal l diet. That is, they believed i t was okay to eat some unhealthy foods as long as they d id not eat t o o much t o o of ten and the rest o f the foods in their diet were healthy. .. .the shake and bake chicken l ike we had last night w i t h the skin o n i t , and I r ipped the piece o f skin o f f and ate that. L i k e i t was SO G O O D , ( laughter) B u t i t was SO B A D , really that 's l ike b ig t ime cholesterol in that. ... ( B u t ) no last n ight 's dinner d idn ' t bother me because the rest o f the dinner was fine. W e had potatoes and vegetables and that was, the rest o f it was all appropriate. A n d I only had one piece o f skin, so i t wasn ' t a B I G fai l ing or- So I th ink all I w o u l d be is conscious o f that fo r the next few days and remember ... not t o go t o M c D o n a l d ' s today whi le I ' m in Vancouver ... t ry and keep the fat out o f m y foods fo r the next few days, sort o f compensation or- I w o u l d n ' t call i t punishment. ... I don ' t th ink I ' d punish myself. (Nancy) 9 7 R E S U L T S The extent to w h i c h informants balanced unhealthy foods w i t h healthy foods in their overal l diet var ied from indiv idual to individual. Kev in , for example, placed h imsel f ha l fway between a to ta l ly unhealthy diet and a tota l ly healthy diet: I t ' s hard to go from ful l left t o fu l l r ight. I f I was centre, I ' d have hal fway to go and i t w o u l d n ' t be so bad, I think. B u t to go fu l l r ight, i t ' s - I t w i l l be very hard. I don ' t th ink I can even do i t t o be honest w i t h you. Fu l l r ight to me in this context w o u l d be l ike my friend at w o r k that eats raw vegetables ... br ings his o w n f o o d in and he w o r k s out five days a week, runs the other t w o . I g o t t o admit, the guy 's in great fantastic shape. H e ' s go t a great body, very muscular, not too much fat on h im whatsoever. I admire h im fo r that. I th ink that 's good. That 's not go ing to be me. I k n o w I can' t do that. S o i f l c a n g o towards the r ight where he is, but maybe ( laughing) maybe halfway. M a y b e I can do that. (Kev in ) A f te r K e v i n used a scale to place himself w i th in the cont inuum o f unhealthy t o healthy eating, I used this t o o l w i t h a few other informants to explore the factors w h i c h inf luenced the process o f mak ing changes. Nancy easily placed herself on the cont inuum from healthy to unhealthy eating and was comfortable discussing her diet in the context o f her overal l intake. She said she was probably 7 0 % towards the high-fat end when she was first diagnosed (she was never "real ly aw fu l " ) , but at the t ime o f the interview she was closer t o the 3 0 % range ( " I ' m not excellent because then I 'd be dr inking coffee black ... or w i t h sk im mi lk , o r whatever, but I ' m definitely w a y more that d i rect ion") . Hav ing an overal l diet approach seemed t o encourage flexibility i n diet planning and permi t inclusion o f a w ide r var iety o f foods in the diet. Wh i le healthy and unhealthy foods was the most c o m m o n classif ication d ichotomy, some informants also made a dist inct ion between foods that were plain, tedious o r dul l , and those that were excit ing, interesting or pleasant. Plain, tedious or dul l foods included cold cereal, porr idge, toast w i thou t butter, vegetables, and chicken. These were foods informants 98 R E S U L T S thought they were supposed to eat or should eat more often. I n contrast, exci t ing, interesting or pleasant foods included eggs and bacon, chips and dip, granola, roast chicken w i t h bacon on top . Wh i le these foods had "taste," they were the foods informants thought they were not supposed t o eat o r should eat less often. For example, Steve said that having co ld cereals w i t h no added sugar or salt, some sliced frui t , sk im mi lk , toast w i thou t but ter and coffee fo r breakfast gets pret ty tedious after several years. H e thought i t w o u l d be " m o r e interesting to have ... some eggs and bacon and toast and ... all that s tu f f that (he) used t o eat." I n terms o f f o o d appropriateness, the discussion be low indicates the specific f o o d components and foods w h i c h the informants were concerned about. Appropriate and Inappropriate Food Components W i t h respect t o individual food items, the informants predominant ly dif ferentiated between foods that had high or l o w fat contents, as we l l as methods o f f o o d preparat ion that were higher o r lower in fat. I n fact, fat was the only food component all o f the informants were concerned about, and the only one wh ich concerned Bruce, Grace, V ic to r ia , D o u g , Nancy and Tracy. W h e n asked about the changes they had made to their diet, their responses focused on fat and the fat in foods. Some informants even talked about using a specific number o f fat grams as a guide fo r their daily fat intake. For example: W h a t I do is I F I N D O U T about what the F A T content is and then I t r y to eat 50 grams of, I t r y to have about 50 grams o f fat in a day. That 's what I t r y to do. L i k e based on this idea o f a really simple target, a S I M P L E target o f 50 grams o f fat i n a day, and ... having an envelope l ike that t o make your decisions in , i t really was helpful. (Bruce) Sugar, calories, salt and cholesterol were also mentioned frequently dur ing the interviews, but only by informants fo r w h o m they were personally relevant (e.g., those w h o wanted to lose 99 R E S U L T S weight , had h igh tr iglycerides or h igh b lood pressure). Fibre, alcohol, prote in, and carbohydrates, as we l l as monounsaturated, polyunsaturated and saturated fats were ment ioned much less often. Several informants were concerned about sugar and fat, but in most cases these informants had high tr iglyceride levels. For example, Steve was t o l d at the L i p i d Cl inic to "avo id fat, alcohol, and sugar in that order o f pr ior i ty , " therefore he "became concerned about all three o f t hem. " Fat, however, was still their pr imary concern. Janice was also equally concerned about sugar and fat because she has a strong fami ly history o f diabetes. A l t h o u g h she herself d id not have diabetes, she had had problems w i t h her b lood sugar level i n the past. Fur thermore, she believed she was sugar sensitive and thought i t was better i f she kept sugar out o f her diet: I f y o u don ' t have sugar fo r months you don ' t have any desire fo r sugar, but once y o u let i t come into your diet i t affects your b lood sugar level and w h e n y o u r b lood sugar drops l o w y o u have that desire to go and have sugar. (Janice) I n addi t ion t o fat and sugar, Janice was also concerned about calories (because she wanted t o lose we igh t ) , carbohydrates and protein. A t the t ime o f the f irst in terv iew she said she had a higher carbohydrate intake and a lower protein intake as a result o f eating less fat. E ight months later she was fo l low ing a different "eat ing p rog ram" whereby she sti l l watched fat, but she was eating more prote in and much less carbohydrate than she d id previously. Aga in , this new w a y o f eating was related to her concerns about the effect some foods have o n her b lood sugar level. Claudia was also concerned about several f o o d components; nonetheless many o f her concerns were related to other condit ions and factors. She watched salt because she has h igh 100 R E S U L T S b lood pressure. She tr ied to increase her fibre intake because she was to ld " that was g o o d . " She watched calories because she wanted t o lose weight. Final ly, she watched sugar because her mother had diabetes (al though she herself d id not ) and she believed that people eat t o o much sugar. I n terms o f dietary cholesterol, Claudia reported not only k n o w i n g h o w much cholesterol is in foods, but also that " your body produces cholesterol even w h e n y o u do not eat any." Thus she believed i t was okay to have some cholesterol in her diet. I n relat ion to having h igh cholesterol, Claudia was also mainly concerned about the fat content o f foods. A l t h o u g h the informants were very concerned about fat, they were much less concerned about the various types o f fat. Only five informants ment ioned dif ferent types o f fats or oils. Janice said she "does not l ike the w o r d saturated" and M a t t "was t ry ing to ... eliminate fat generally, and saturated fat specifically" from his diet. Tracy thought about "saturated versus unsaturated and trans fat ty acids and all that sort o f t h i n g . " Nancy ta lked about dif ferent types o f oils. For example: I l o o k at the ingredients on something and i f i t says i t ' s 0.3 grams o f fat, but then I l o o k and see that i t 's C O C O N U T oi l or P A L M oi l , then i t doesn' t really matter that i t ' s low- fat , i t 's the W R O N G k ind o f low- fat . I don ' t wan t that at all. (Nancy) Claudia also avoided palm oi l , coconut o i l and hydrogenated fats. The other informants were only concerned about fat i n general. Similarly, dietary cholesterol was not much o f a concern fo r most informants. Richard was mainly concerned about fat; however, when food labels o r packages prov ided cholesterol in fo rmat ion he said he t o o k note o f i t and made purchasing decisions based on it. Grace also ment ioned dietary cholesterol in relat ion to food labels, but went on to say: I f I saw something " low- /no-cholestero l " I 'd buy i t th ink ing " O h that 's great." I t t o o k me a few years fo r i t t o sink in and to finally realize that doesn' t really 101 R E S U L T S mean that much. I f i t ' s " low- /no-cholestero l " there could sti l l be a lo t o f fat in that same product . (Grace) Therefore, i t was stil l the fat content o f products that she was concerned about. Other informants occasionally mentioned dietary cholesterol, but fat was the f o o d component they were most concerned about. T h e informants ' major concerns about fat and minor concerns about sugar, salt, and cholesterol were in keeping w i t h the nutr i t ion education in format ion prov ided at the L i p i d Cl inic (D ie t F o r A Heal thy Heart , Mod i f i ed Fat Diet , Fat Facts, H o t Ideas F o r Summer Eat ing, G o t The Munchies?, Eat ing Lean O n The R u n A t Lunch , Qu ick and Lean Ideas, and Eat ing Ou t Tips) . W i t h the exception o f sugar and calories wh ich were related t o weight and/or t r ig lycer ide levels, food components other than fat were generally related to other health concerns. Appropriate and Inappropriate Foods I n keeping w i t h their concern about the amount o f fat they consumed, all o f the informants said they were t ry ing t o eat less fat o r fewer high-fat foods. Some informants were also sl ightly concerned about the cholesterol, sugar, salt and calories in foods and several were t r y ing t o reduce their alcohol intake. Table 4.3 lists the main foods informants were concerned about and tr ied to eat less of. Similarly, informants t r ied to eat more foods that were l o w or lower i n fat or had no fat at all. I n general, they ate more vegetables, f ru i t and grains o r carbohydrates to compensate fo r their lower- fat intake. Aga in , some informants were also interested in foods l o w in cholesterol, sugar and/or salt. Table 4.4 lists the main foods informants t r ied to eat more of. Several informants also believed dr ink ing more red w ine may help lower their b lood cholesterol levels and/or improve their H D L levels. One 102 R E S U L T S Table 4.3 Common Foods Informants Try To Eat Less Of4 butter and/or margarine mayonnaise cheese who le and 2 % mi l k o i l gravy cream sauces regular salad dressings f r ied foods French fries potato chips meat and/or red meat beef steak roast regular g round beef hamburgers bacon fat on meat/chicken skin desserts^aked goods ice cream cookies Table 4.4 Common Foods Informants Try To Eat More Of lean meat o r leaner cuts sk im or 1 % mi l k chicken yogur t tu rkey cottage cheese extra-lean ground beef low- fa t cheese fish low- fa t cookies pasta f ru i t who le wheat o r b r o w n bread vegetables r ice tomato sauces canola o i l salad 4 Foods listed were mentioned by at least four informants. 103 R E S U L T S in formant in part icular made sure she drank red wine when she ate something " fa t t y . " I also heard about w ine and so I have some red wine w i t h m y meal. W e l l not every t ime because i t ' s so expensive (laughter) but I have i t once in a wh i le w i t h m y meal, i f I ' m having anything fatty. I th ink " W e l l I ' m go ing t o have red w ine w i t h th is" but I t ry and keep everything down. (Claudia) M o s t o f the foods informants t r ied to eat more o f were substitutes fo r foods that were higher i n certain f o o d components. For example, lean meats and leaner cuts o f meat were consumed in place o f higher fat meats. L o w - f a t or lower- fat products were substituted fo r high-fat products. D ie t f o o d and no added sugar foods were eaten in place o f non-diet f o o d or foods that were higher i n sugar. Finally, unsalted foods replaced high salt foods. 4.3.1.2. K n o w i n g W h a t T o E a t T o reach decisions on what they should or should not eat, informants went th rough a process o f gathering in format ion to find out wh ich foods were heart healthy. Var ious sources o f in fo rmat ion helped them learn what they should do to mod i fy their diet, such as the doctors, dietit ians and brochures at the L i p i d Clinic, the media ( inc luding television, newspapers, magazines, radio, and books) , recipe books, and other people ( inc luding friends, spouses, o r relatives). Informants also used " c o m m o n sense" to decide h o w to mod i f y their diets. F o r example: W h e n I buy certain things I ' l l take a l ook at the, part icularly the cholesterol count, and then I ' l l l ook at the fat count, but I just basically go w i t h in tu i t ion as to what I - Y o u k n o w there are certain things you k n o w have a h igh fat content, so I jus t avoid those. (Richard) I n addi t ion t b the sources o f in format ion mentioned above, society in general helped the informants determine h o w they should modi fy their diets. For example, w h e n asked about the places where he had picked up t ips on preparation, Bruce replied: 104 R E S U L T S W e l l out o f books and newspapers and that, and also l istening to the radio and watch ing T V and y o u ' d see- There's all k inds- I mean all y o u have t o do is l o o k and y o u see all kinds of, everybody's tel l ing you h o w to eat w i t h o u t fat. A n d then when y o u really, A N D when y o u actually th ink about i t i t ' s qui te simple, jus t b ro i l i t . . . take the skin of f . . . (Bruce) Once the informants had learned h o w to modi fy their diets, many used f o o d labels as a source o f in fo rmat ion t o decide what foods t o eat o r not eat. F o r some informants learning h o w to modi fy their diets was a process that required t ime fo r the in format ion to sink in or make sense. For example: W e l l the f irst t ime I came in I had a l i t t le yak w i t h the dietit ians and so I d id what I thought that was, wh ich was to eat less meat and this, that, and the other. I t really d idn ' t make any difference, after six months i t made no difference at all. A n d then so I had a l i t t le more serious ta lk w i t h the nutr i t ionist and at that point found out that really the preparat ion and al l o f that i n cook ing had made a significance, had to be- I had made a b ig mistake about it. I thought that you just put less mayonnaise o n and less but ter and that k ind o f th ing. I n fact I had to really make a significant change. (Bruce) Similarly, most informants d id not stop gathering in format ion after they learned h o w to mod i f y their diets. Instead, they sought out o r paid attent ion t o any n e w in fo rmat ion about b lood l ip id levels and/or heart disease as i t became available to them. Claudia said every t ime there is something on television about cholesterol, the heart or b lood pressure she listens t o it. K e v i n also p icked up o n new informat ion he saw on television, wh i le Anne said she paid at tent ion to "every l i t t le bi t o f in format ion" she saw. Janice obtained new in format ion f r o m the newspapers. Whether o r not informants actively searched fo r or were receptive to new in format ion seemed t o depend on h o w concerned they were about having h igh b lood l ip id levels (as explained in the section on Becoming Mot i va ted ) and h o w mot iva ted they were to make changes. Be ing receptive or open to new in format ion helped the informants find out more about the condi t ion and what they could do about it. Wh i le a f e w informants were 105 R E S U L T S content w i t h the in format ion they were given at the L i p i d Clinic, others were more interested in finding out as much as they could. Those w i t h a definite interest i n gather ing in format ion were more l ikely t o gather in format ion from more than one source. I went to the L i p i d Clinic and then the dietitians helped me, and then I started do ing a lo t o f reading. I just read bits and pieces ( in magazines and newspapers) and- Sometimes you see a headline "Cholestero l " and y o u th ink " O h h h I ' l l read that ." L i k e things that, anything about cholesterol and then ta lk ing to people that had high cholesterol. (Grace) A t t imes, informants found that new informat ion conf l icted w i t h previous in format ion they had received. Fo r example, Grace was surprised and confused w h e n dietit ians o n television said " i t ' s okay to eat more than three eggs a week" o r " i t ' s okay t o eat chocolate that isn ' t l ight . " She said i t was "mind-bogg l ing" because she has always been t o l d to do the opposite. Other informants mentioned the confl ict between the in format ion from the L i p i d Cl in ic about avoid ing alcohol (especially i f they had high tr iglycerides) and wha t they heard about red w ine 's abil i ty to assist the body in handling fats. N e w in format ion was not only sometimes regarded w i t h skepticism because i t was contradictory, but also because the nature o f that in format ion seemed to change too frequently. A n d , even as I said, the medical profession's perspective o n cholesterol levels and s tuf f has changed over the last 20 years. So a lot o f people are go ing to say t o themselves " W e l l what they said last year, they ' re saying is w r o n g this year, so what do I care because maybe that 's w r o n g next year." So i t ' s pret ty easy t o tu rn o f f things that make your l i fe dif f icult or less enjoyable. ( M a t t ) I t is important to emphasize the dist inct ion between gathering in format ion and acting o n it. A f e w informants articulated that know ing what to eat and actually being able t o eat that w a y were t w o distinct things. For example, when I probed to find out where V i c t o r i a found out about the changes she described, she replied: N o I K N E W about it. I mean fo r one thing, remember I do a lo t o f these (medical) reports and everything. K n o w i n g and doing are t w o separate things. 106 R E S U L T S A n d one has read and one is A W A R E o f articles and what have you , but k n o w i n g and do ing are t w o separate things. (V ic to r ia ) 4.3.2. E s t a b l i s h i n g H e a l t h y E a t i n g B e h a v i o u r s F igure 4 .1 presents an overv iew o f the strategies informants used t o establish healthy eating behaviours. A s indicated, informants used different strategies w h e n eating at home and when eating away f r o m home. The discussion below illustrates h o w they accomplished the var ious strategies. 4 . 3 . 2 . 1 . A t H o m e The strategies informants used at home included eating less, eating more, substi tut ing foods and altering the method o f preparation. I n general, these strategies helped informants include a var iety o f foods in their diets and minimized the el iminat ion o f one o r more o f the four f o o d groups (such as meat or dairy products). E a t i n g Less W h e n describing what they do when they are at home, all o f the informants ta lked about eating less o f certain foods. One strategy used to accomplish this was eating foods less often, as indicated by comments about eating some foods "once in a wh i le , " "on ly occasional ly" and " a lo t less o f ten. " I L I K E steak and I L I K E roast and w e ate quite a bi t o f it. So what happened was w e jus t ate smaller port ions and ate i t a L O T less often. L i k e a L O T less often. (Bruce) Similarly, Richard had ice cream "once every six months" and had "bacon and eggs and the who le w o r k s once a month . " Several informants referred to foods they ate less of ten as treats. F o r example, Steve v iewed cheese, butter and desserts as treats because he only had 107 R E S U L T S A T H O M E : • Eat ing Less Eat ing Foods Less Frequently Eat ing Foods I n Smaller Amounts El iminat ing Foods Completely V i r tua l ly El iminat ing Foods -Eat ing foods much less of ten and in smaller amounts • Eat ing M o r e Eat ing Foods Natura l ly L o w I n Fat and/or Cholesterol e.g., f rui t , vegetables, grains, f ish, chicken Eat ing Foods Natura l ly L o w I n Sugar or Salt • Substi tut ing Foods Eat ing Lower -Fa t Products T o Reduce Fat Intake e.g., low- fa t cheese, sk im mi lk , extra lean ground beef Eat ing Diet /Unsalted Foods T o Reduce Sugar/Salt In take • A l te r ing The M e t h o d O f Preparation Remov ing /Tr imming Visible Fat Us ing Non-S t i ck Cookware Us ing Lower -Fa t Methods o f Preparation e.g., baking, broi l ing, poaching, barbecuing, and fast f ry ing A W A Y F R O M H O M E (In Restaurants/In Others' Homes): • Order ing/Choosing Careful ly • Eat ing Selectively Us ing self-control t o eat less o f or avoid certain foods w h e n less in cont ro l o f the foods available and/or h o w it was prepared • M a k i n g The Best o f I t • L i m i t i n g the Frequency o f the Event Figure 4.1 Establishing Healthy Eating Behaviours 108 R E S U L T S them on special occasions. Grace also talked about having something occasionally as a treat: I loved a roast with, a roast pork with all that fat on it. Now that's something I just have it once in a long time for a treat. (Grace). In general, informants tried to eat foods that were high in fat less often; however, some informants also tried to eat less of desserts that were high in sugar and Claudia ate canned soups less often because they were high in salt. Eating foods in smaller amounts or smaller portions was another way informants ate less of the foods they felt were inappropriate. "Eating very little," "limiting," and "taking less" were all ways they talked about eating smaller amounts of foods. Informants used various techniques to ensure they ate smaller portions. For example, to assess an appropriate portion size, Bruce looked at the suggested serving size on a label and, once he knew how much fat was in a specific amount, he "just tries to have that much." Claudia controlled the portion size of the red meat she ate either by weighing it or by having only half of a small piece. When Steve had scrambled eggs or a piece of dessert he shared it with his wife in order to reduce the size of his portion. Richard used a small dish to ensure he had less ice cream. Overall, the foods informants tried to have smaller portions of included the high fat foods listed in Table 4.3. Some desserts and "sweets" were also eaten in smaller amounts in order to reduce the amount of sugar consumed and some informants ate smaller amounts of shrimp because it was high in cholesterol. In addition to eating foods less often and in smaller amounts, the informants also ate less by eliminating foods. For some, eliminating foods was the preferred way to eat less of foods they felt they should not be eating. That is, they stopped eating or "cut out" certain foods. For example: 109 R E S U L T S I jus t stopped (eating sausage). Per iod I found that I had to stop, per iod. A n d the same th ing w i t h cookies and chips and all o f that stuff. I jus t had t o stop. (Bruce) A n d no butter. I don ' t touch the stuff. I don ' t even l ook at butter. I had ice cream the odd t ime and I 've cut that out completely n o w because I f igure-A n d I l ike chocolate chip cookies and I don ' t l ook at them anymore. (Claudia) A s a who le , the informants reported eliminating foods that were h igh i n fat. They el iminated " b i g fat ty th ings," "unnecessary fat ty foods, " "anything that looks fa t ty , " and " th ings w i t h a high-fat content ." I n addit ion to the foods mentioned in the quote above, other higher-fat foods ehminated by some o f the informants include red meats, skin o r fat f r o m meat, cheese, f r ied foods, and desserts. Some foods, such as prepared meats, processed o r convenience foods, f ru i t ju ices, as we l l as some desserts, were eliminated by some informants because o f their sugar or salt content. I n contrast t o completely el iminating foods, there were some foods informants preferred t o virtually eliminate. V i r tua l ly el iminating foods involved t w o propert ies: eating foods m u c h less o f ten and i n smaller amounts. Some informants repor ted el iminat ing foods that in fact they had only v i r tual ly eliminated. For example, Bruce said he "does not eat eggs n o w " and he had "cu t ( them) right ou t " ; nonetheless, later he said he had an egg once a month. Other informants readily acknowledged that there were some foods they sti l l ate, albeit much less of ten and in smaller amounts. The fo l low ing quotes i l lustrate bo th propert ies o f v i r tua l ly el iminat ing foods. I v i r tual ly never have butter. Occasionally when w e go out, i f w e g o to a restaurant where they serve something l ike a nice H O T bread, we l l then that w i l l be a treat t oo and I ' l l put a l i t t le bit o f butter on that, but only a l i t t le. (Steve) . . . ice cream, I always loved ice cream, and I ' ve vir tual ly g iven that up. M a y b e once every six weeks I ' l l have a small dish. (Richard) 110 R E S U L T S Again, it was the fat content of foods that the informants were concerned about when they talked about virtually eliminating foods. The above discussion outlined the factors involved in eating less, namely, eating foods less often, eating them in smaller amounts, eliminating foods, and virtually eliminating foods. No informant relied on any one strategy to eat less of inappropriate foods. Instead, different strategies were used for different foods. In most cases, the eating less strategy did not mean that informants were eating a smaller amount of food. That is, with the exception of Claudia and Doug, the informants were not "dieting." In fact, several were quite clear that the process of making changes was not a (reducing) diet. It was "a lifestyle change ... not a diet." For example: (My wife) told me that I should consider ... going on a Weight Watchers diet, but I found- I tried it for a bit and the reduction in calories was SO high that I just felt hungry ALL the time. And I couldn't deal with it. Being hungry all the time just made me SO SNARLY. And I just- I wasn't- I just couldn't deal with it. Whereas I found with cutting out, back the fat I was able to get enough carbohydrates and bulk and so on in me, I didn't FEEL hungry all the time. And having an apple or something once in a while. And it was REALLY, really much more easy for me to deal with than, than just hacking calories. (Matt) Like 15 years ago "Okay I'm going to lose weight." All right then you eat cottage cheese and salads ... that's it. That's how you had a diet. Now you can have a diet in a hundred different ways and still be "on a diet." Which I don't like that word, in the sense I want to lose weight, but I'm not going to go on a diet. I'm going to CHANGE what I eat and it's not going to happen overnight. I'm not on a diet, I'm changing the diet. So that I can eat, so I can pig out at dinner, but there was nothing there, (laughing) There was nothing that was harmful to me. (Nancy) Tracy said she was not "dieting" because eating less or going on a reducing diet caused her to feel deprived and would prevent her from making or maintaining changes. In order to eat less of certain foods without dieting, the informants were eating more of other foods. I l l RESULTS E a t i n g M o r e As they talked about eating less of some foods, informants also discussed eating more of other foods so they would feel "satisfied" or "not go hungry." That is, they were eating more of healthier foods (such as vegetables, fruits, pasta, and rice) to compensate for the reduction in calories from eating less of or eliminating unhealthy foods. A stir-fry is very good. And I like stir-fry. And it looks like you're eating A L O T and you really have just vegetables cut up and a little bit of meat, but I find it quite satisfying. (Claudia) Overall, the foods informants ate more of included the lower-fat foods listed in Table 4.4. S u b s t i t u t i n g Foods Another strategy informants used to modify their intake of some foods was to substitute certain foods for higher-fat, higher-sugar, and/or higher-salt foods or products. Some of the lower-fat substitutes included skim or 1 % milk (vs. 2 % , whole milk, or cream), low-fat cheese, low-fat frozen yogurt (vs. ice cream), extra-lean ground beef, low-fat cookies, low-fat snack foods, tomato sauces (vs. cream sauces), as well as leaner cuts of meat and types of meat that are lower in fat (such as chicken, white turkey meat, fish and seafood). Most informants reported reading labels to ensure that a product was truly a lower-fat choice. Other substitutions were made by some informants to reduce the amount of sugar and salt they consumed. For example, diet pop was substituted for regular pop, and unsalted foods replaced salted foods. A l t e r i n g T h e M e t h o d o f P r e p a r a t i o n Informants also recognized that the preparation and cooking of food was a significant factor in changing their eating behaviours; consequently, many of them liked to prepare their 112 R E S U L T S own food at home. Common strategies to alter the method of preparation included taking the skin off chicken, trimming any remaining fat visible on meat, using non-stick cookware that required little or no added oil, and switching to lower-fat methods of preparation, such as baking, broiling, poaching, fast frying, and barbecuing. Steve liked to barbecue meat because it allowed the fat to drip off during the cooking process. We pull the skin off chicken, and then I actually trim any fat that I can see underneath that, and then, unless the weather is very inclement, we barbecue it on a gas barbecue. And by that means we don't carry the fat that comes out of the meat and is in the frying pan, we don't- We avoid that as well. (Steve) 4.3.2.2. Away From Home The informants reported that when they were away from home, they were often faced with situations in which they were less in control of where they ate or what foods were available for them to eat. Eating situations away from home included eating at restaurants or at someone else's home. Although there were times when the informants reported eating foods they normally would not eat (e.g., special occasions, treats or when they had no other choice), they generally tried to eat as best they could. The strategies they used to stay on track and/or avoid temptations included ordering carefully, eating selectively, making the best of it, and limiting the frequency of the event. Ordering Carefully Ordering carefully in restaurants was a strategy informants used to keep their fat intake down. For example, Bruce said "in a restaurant you have to accept that there is going to be a lot fat in things and you have to order carefully." Some informants were less concerned about what they ordered in restaurants because eating out was a special occasion and/or rare event for them. However, most of them tried to order the leanest type of meal, 113 RESULTS such as pasta with tomato sauce. Many considered what was in the food and were careful when they ordered. I order carefully. I like salad, but then some salads are worse than- (laughing) I mean you can have a lot of calories in some salads. So I would order a salad and ask them to put the dressing in a little container rather than putting it on the salad for me. That way I can control it. That sort of thing. And then I don't normally order desserts because it gets too expensive to eat out anyway. So that leaves me with the entree and I don't order pasta with heavy cream sauces. I don't order anything that's, anything with cream on it. So it'd be mainly something like a lean piece of beef, which I don't normally have at home, I might have it in a restaurant, lean piece of steak with vegetables. But normally there's no heavy gravy, or if there is, it would be just a little bit. But I'm not a cream person, like pasta with all this cream and- I don't go for that. Not that I wouldn't enjoy it, but I know it's not good for me. (Janice) For some informants, ordering carefully involved asking questions and/or making requests because it was not always possible to determine how foods were prepared. Typically, informants asked questions about how food was prepared. Others knew what they wanted and made requests accordingly. So that's one of the kinds of strategies I guess is that when I go out I try and go somewhere that either has the menu items or is willing to modify menu items so you can get just what you're targeting. (Matt) Common requests included asking for a salad instead of fries, asking for the salad dressing on the side or asking for low-calorie salad dressing, asking for the skin to be taken off chicken, asking for a tomato sauce instead of a cream sauce, asking for sandwiches without butter or mayonnaise, and asking for milk instead of cream for coffee. Exercising self-control was important in restaurant situations because of the variety of inappropriate and tempting foods available. Even if they ordered carefully, they did not have full control over the preparation of the food. (When you're at a restaurant) it's a little bit more difficult I think generally. I think when you get, do more of your own food preparation or whatever, whether it's for lunches or at home, there's more control of the kinds of things 114 RESULTS that ... your intake and what you're eating and how it's prepared. You don't always know a lot of this stuff. I don't. I don't always know how some of things are prepared. Sometimes you, you can't know. (There's more control when you're preparing the foods at home because) there are certain things that you just don't, they're not there. ... I think, when you go shopping you can completely avoid getting these things, buying them. You go, you get the certain kind of margarine (laughing) or whatever ... and that's the only thing you have. So there, I think, there's a tremendous lot of control that you can, one can have at home. (Oliver) Also, not only did informants experience temptation because of the foods available, but often the people they were eating with ordered inappropriate foods as well. And it, that is a little bit difficult because you're all eating, and they're ordering this and they're ordering that and I think "No I can't have that" so I have my little piece offish and no (laughing) and no dessert. (Claudia) To minimize the temptation to eat inappropriate foods, some informants carefully selected the type of restaurant they went to. Steve was careful at Chinese and Italian restaurants, but at seafood restaurants he found it hard not to order fish and chips. Therefore, choosing to go to restaurants where appropriate foods were available increased the amount of control informants had over the foods available to them. Whereas a lot of places you go, they have a more fixed lunch menu. They're not as amenable to changing the product that they deliver to the table. And some places you go there's just NOTHING ON THE MENU THAT'S LOW r N FAT. Pubs are the worst. They have almost nothing that you can order that's low in fat. And when you try to, often times it doesn't come the way you ordered it and then you have to go through the hassle of trying to deal with that. So I found that, in fact, eating at more (laughing) expensive restaurants was, made it easier for me to maintain the diet because they were much more amenable to making the change that I wanted. And they, they tended to have more choices along the lighter menu items as well. So the selection of restaurant made a significant difference in what their menu offered and, as I say, in addition how willing they are to customize the product they deliver to your table. So ... it's a very large difference. (Matt) It was easier for them to order appropriate foods if more were available on the menu. Consequently, some informants tended to select Italian, Chinese, and Japanese restaurants 115 RESULTS more often, wh i le avoiding fast f o o d restaurants or those that d id not of fer anything that was l o w in fat. E a t i n g Select ively Eat ing selectively refers to informants ' efforts to contro l what foods they ate and h o w much they ate. This strategy was used when informants had less cont ro l over what foods were available t o them and/or h o w those foods were prepared, such as w h e n there was a var iety o f f o o d t o choose from (e.g., in restaurants), or when there was very l i t t le choice available (e.g., at other people's houses or when travel ing). Aga in , i n these situations they on ly had con t ro l over the specific foods they ate and/or h o w much they ate. Ac tua l ly (when I t ravel) i t ' s a set meal usually, and it's put before you . So I -Y o u have t o eat it. B u t I mean i f i t 's anything very fat ty I ' d , I w o u l d n ' t , I guess I w o u l d put i t aside. (Claudia) W h e n informants selected certain foods for themselves (such as in restaurants) eating selectively combined some o f the strategies already discussed above, such as eating a smaller amount or eating less o f specific items. Occasionally Steve and Grace went out w i t h friends fo r fish and chips; however, they reduced the amount o f fat they consumed by remov ing the batter and no t eating some or all o f it, and by not eating all o f the chips. F o r example: ... l ike they give you lots o f chips and I usually just eat a f e w o f them ... and I always take the batter o f f the fish. I never eat the batter. I love i t , but I k n o w i t ' s so fu l l o f wha t y o u shouldn' t have. (Grace) Anne also ta lked about being selective about what she ate on her plate: I had oysters in Bos ton and it was gratin. A n d it ... had the, I k n o w had the but ter in so I was sort o f pushing, pul l ing the oyster out o f i t and draining i t sort of. A n d that was a treat because I normal ly w o u l d n ' t have ordered that. B u t being i n B o s t o n I had to . (Anne) I n situations w h e n there was choice, most informants were selective about the amount o f fat 116 RESULTS they ate and tended to select lower fat foods instead o f the higher-fat food . F o r example, at a work- re la ted smorgasbord Steve selected the "heal thy" foods ( f ru i t and vegetables) and d id no t eat the f o o d h igh in fat (pizza) even though he w o u l d have preferred t o have a piece o f pizza. Similarly, at a family barbecue Richard ate the vegetables and salads, and avoided the red meat, preferr ing to wa i t unt i l he returned home to have some chicken or f ish. M a n y informants also refrained f r o m ordering desserts in restaurants or shared a piece w i t h someone else so they on ly had a small amount. Ea t ing selectively at other people's homes was more di f f icul t because o f the social norms regarding hospital i ty and politeness. Informants were generally very conscious o f the foods served and h o w they were prepared and observed that of ten the foods served tended to be h igh in fat (e.g. , vegetables cooked w i t h butter and covered w i t h a cheese sauce). N a n c y ' s comment i l lustrates the di f f icul ty many informants had when their fr iends prepared foods they d id not normal ly eat: I f they were to give me chicken w i t h the skin on it, I w o u l d take the skin off. I f there was a cream sauce that I K N E W was made w i t h wh ipp ing cream I w o u l d t r y and ask for a small por t ion and I ' d probably lie and say something l ike " I ' m not very hungry" or whatever. Rather than saying " Y o u made that w i t h wh ipp ing cream and I can't eat that" or . . . Because i t ' s not an al lergy and tha t ' s the th ing, y o u can ' t - I f you ' re allergic t o cashews y o u can te l l somebody that y o u can ' t eat their food because o f that. B u t I ' m not allergic to wh ipp ing cream, i t ' s just not good fo r you (laughing) so i t ' s hard to tel l some ... hard t o say to that person. (Nancy) Some informants found i t di f f icul t t o eat at other people's houses because o f the pressures to jus t have a l i t t le bit. That is, other people were not support ive o f their desire to not eat certain foods. F o r example: A lo t o f t imes the tendency o n part o f a lo t o f people seems t o be that " O h w e l l jus t this once you can have a steak or y o u can have th is" and as I say i f 117 RESULTS everybody says that and then eventually you 've lost you r momentum. (Richard) I n order to "po l i te ly refuse or reduce the amount o f f o o d that is served and preferred by the host, w i t h o u t turn ing up (his) nose at their hospital i ty," Steve said he asks fo r more vegetables and less meat. Nancy used eating at other people's homes to educate or i n f o r m others o f her desire to eat healthy foods in order to garner social support. W e ' r e i n a dinner club w i t h - This is our second year. A n d I th ink last year I made a point - W e went on a weekend t r ip w i t h our dinner club and so one Sunday w e had the ful l - fat sour cream and l ike guacamole and all the things and I ' m sort o f chastising them because w e ' r e all in that f un t ime of . . . y o u k n o w . So I ' m shaking m y f inger at them and saying " Y o u k n o w there's other products that y o u can buy and i t tastes jus t as good. A n d y o u ' r e pu t t ing i t in to a si tuat ion where you can' t tel l whether, what 's there anyways so w h y not use the less- fat . . . " A n d so w e ' d laugh together about Nancy 's preferences and h o w Nancy 's t ry ing to make us all more healthy. B u t at the same t ime I th ink they ' re gaining, they ' re actually realizing that i t 's not t oo bad fo r them either. (Nancy) Nancy said i t was easier to refuse certain foods w i t h closer fr iends because she was not wo r r i ed about "stepping on their toes." Interestingly, several informants ta lked about serving their fr iends foods they w o u l d prefer not to eat themselves. Fo r example, Claudia w o u l d stil l make a roast when she had company, even though she eliminated most red meat from her diet. Anne provides another example: I w i l l prepare a meal that I k n o w people w i l l l ike and i t doesn' t matter i f I d o n ' t eat it. I f I can, I can do w i thout o r I can eat a l i t t le bi t o f it. B u t i f people. . . There are things that that our friends, that some o f our friends l ike and enjoy, so w e ' l l provide that k ind o f f o o d when w e are entertaining them. L i k e w e make up a rice and peas dish which, I find is delicious w i t h o u t coconut mi lk , bu t i n Jamaica i t ' s made w i t h coconut m i l k and our friends here l ike i t w i t h coconut m i l k (pause) and so we M A Y make a pot w i t h coconut m i l k and one w i thou t sort o f th ing. (Anne) Sel f -control was also an important aspect o f eating selectively. That is, eating selectively away from home required the informants to apply a greater degree o f sel f -control 118 RESULTS than w h e n they modi f ied their eating behaviours at home. Even though sel f -control was necessary to establish healthy eating behaviour at home, i t seemed to be more impor tant when the informants ate away f r o m home because the temptations were greater. In formants had to use sel f -control t o order carefully, eat less o f what was placed before them and/or only eat specific i tems o n the plate. ( W h e n you ' re eating in a restaurant) they 'd go broke i f they served y o u a l i t t le meal, so they give y o u a huge amount o f f o o d and they charge y o u a lo t o f money fo r i t ... and then i t ' s there, and h o w much do y o u send back? I t ' s d i f f icul t t o only eat a certain amount. (Bruce) Overal l , i t was easier fo r informants to control their eating behaviours at home because they were better able t o contro l the food available to them and, thereby, were able t o reduce the temptat ion to eat inappropriate foods. Bruce said not buy ing inappropriate foods was " just c o m m o n sense" because he did not want those foods. I n contrast, when inappropriate foods were available (whether in the home or when away from home) i t was harder and required more sel f-control f o r the informants not to eat those foods. Several informants ta lked about the dif f icult ies and self-control required in away from home situations. Fo r example: Y o u d o n ' t have as many temptations at home as you have- Y o u can con t ro l wha t ' s i n your fridge, but when you go to a restaurant there's a menu. A n d y o u always say to yourself, you always say " O h I ' m out ... treat yourse l f ... this is a special occasion and w h y not do i t " sort o f th ing. A n d I guess that, i t is a b ig temptat ion. The biggest temptat ion is when y o u ' v e paid fo r something, l ike a smorgasbord and then you go and you got all this f o o d out there. That 's a bad situation to put yoursel f into, unless you ' ve go t lots o f w i l l p o w e r or unless y o u say " O k a y today is a special day and that 's all r ight. I t ' s okay to treat yourself. En joy what 's there." I n moderat ion o f course. A n d I do that sometimes. B u t I don ' t want to do it too often. (Janice) Making the Best of It Another w a y to deal w i t h the availability o f inappropriate foods away from home was to have the att i tude that they had to "make the best o f i t . " 119 RESULTS M y overal l approach is to consume what is recommended t o stay o n the program and that i f I am in a situation where i t ' s not possible, y o u make the best o f i t . I f I g o t o someone else's house fo r dinner, w h i c h is no t very of ten, y o u eat what they have served, but you eat smaller quantities o r y o u eliminate something that y o u - I f they serve yams, you don ' t have to have yams, y o u can have tw ice as much o f another vegetable. I don ' t really focus, I d o n ' t w o r r y about i t anymore. (Janice) Generally, informants were less concerned about having to eat inappropriate foods when they knew i t was only a temporary situation. Steve had " foods outside o f (his) d ie t " (e.g., a couple o f mornings w i t h scrambled eggs) when he visited his daughter, however, he d id not w o r r y about i t because he knew he w o u l d just resume his regular diet when he returned home. H e said i t was " n o b ig deal ... y o u jus t adapt." T o " f i t in w i t h the c r o w d , " he either modi f ied wha t he ate o r adjusted the vo lume o f foods he consumed. Fur thermore, he maintained some o f his regular healthy eating behaviours (such as having dry toast). Bruce, on the other hand, found i t harder t o make the best o f i t when he was out o f t o w n w o r k i n g fo r fou r and a ha l f months because he could not do anything about the constraints o f the situation. That is: I ' d have to go maybe 6, 7 miles to get into t o w n wh ich is where w o r k was, and then I w o u l d either have to G O B A C K to where I l ived and eat there o r else " W e l l , I ' ve go t an hour and a ha l f . . . " So I have to go to a restaurant. (Bruce) Limiting The Frequency O f The Event The frequency that informants ate away from home inf luenced h o w much they were concerned about healthy eating behaviours when they ate out. Fo r example, Steve was less concerned about what he ate in restaurants, because the meals he ate ou t represented a small p ropor t ion o f his to ta l meals, whereas Bruce tr ied not to eat a "huge plate o f pasta" at a restaurant "a l l that o f ten" because he had t o eat out frequently. Claudia w e n t t h rough periods w h e n she hmited the amount that she ate out in order to have more cont ro l over her fat intake. 1 2 0 RESULTS B y avoid ing certain situations, informants were not reminded that they had to w a t c h what they ate and were not tempted to eat inappropriate foods. I t can be a b i t o f a pain in the ass i f you don ' t get to have the th ing that y o u want. Y o u ' r e sort o f sitt ing there th ink ing " N o I w o n ' t have that . " So wha t I t r y t o do is A V O I D gett ing in situations where then I have t o deal w i t h that because then y o u feel l ike you ' re depriving yourself, and then y o u g o ahead and y o u have i t , and then you feel gui l ty about it, and then y o u pound out. So I jus t stay out o f that, whatever that th ing is, entirely. (Bruce) 4.4. The Process of Making Dietary Changes The theoretical f ramework constructed to understand hyperl ip idemic adults' experiences w i t h making dietary changes focuses on the process o f mak ing changes. The factors w h i c h const i tuted and influenced the informants ' dietary change efforts are i l lustrated in the accompanying conceptual model (Figure 4.2). I n accordance w i t h dimensional analysis, " f ind ing a balance" emerged as the central dimension o r perspective w h i c h was used to determine the salience o f other dimensions and organize their placement w i t h i n the theoretical f r amework o f mak ing dietary changes. The process o f making changes starts on the left o f the model w i t h the dr iv ing factors that helped init iate and maintain the change process. Once init iated, the process involved cycles o f making changes, finding a balance, evaluating outcomes and efforts, and making decisions. Cycles o f sl ipping and gett ing back on track were also part o f the change process. Fo l l ow ing evaluat ion o f outcomes and efforts, the process either cont inued o r ended. I f the process ended, the final outcomes were g iv ing up (i.e., returning to o ld eating behaviours) o r maintaining the changes (i.e., adopt ing new eating behaviours). A t any t ime dur ing the process var ious intervening factors were either helpers or barriers to mak ing changes. 121 RESULTS RESULTS In formants ' experiences o f the process o f making changes are discussed under the fo l l ow ing headings: d r iv ing factors, cycles o f making changes, and intervening factors. 4.4.1. Driving Factors Whether o r not informants were resistant or w i l l i ng to init iate o r maintain the change process was influenced by several dr iv ing factors, including h o w mot ivated they were, the extent t o w h i c h they resolved to make changes, and various personal circumstances, such as upbr inging, l iv ing situation, gender, social role, and age o r life-stage. Wh i le these factors can also be conceptual ized as intervening factors, they are identi f ied here as dr iv ing factors because they specifically helped informants init iate or maintain the change process. 4.4.1.1. Becoming Motivated The extent t o wh ich informants became mot ivated to engage in healthy eating behaviours determined whether they made changes and h o w many changes they made. I t was very di f f icul t t o get into the process at that t ime. I wasn ' t part icular ly mot ivated. I t was inconvenient to go and see the diet i t ian there, i t was di f f icul t t o get appointments at a reasonable t ime fo r me. So things k ind o f conspired to give me excuses not t o do anything. ( M a t t ) In formants ' level o f mot iva t ion was established in a process invo lv ing one or more factors, including: a) being concerned about having high b lood l ip id levels; b ) finding personal meaning o r a mot ive f o r making behavioural changes; c ) perceived abil i ty t o make changes; d) establishing a posit ive att i tude; and e) past outcomes or feedback. Being Concerned Be ing concerned about having h igh b lood l ip id levels inf luenced whether informants ini t iated and/or maintained the change process. The extent t o wh ich they were concerned also 123 RESULTS seemed to influence what changes or eating behaviours were or were not acceptable to them. That is, those w h o were more concerned indicated that making changes t o w a r d healthier eating behaviours were acceptable, whi le those w h o were less concerned indicated that some changes t o w a r d healthier eating behaviours were unacceptable. Overal l , their beliefs and att i tudes about several considerations determined the extent to wh ich informants became concerned about having h igh b lood l ip id levels. These considerations included their ou t l ook about being diagnosed w i t h high b lood l ip id levels, the presence o f a fami ly h istory o f C H D , understanding the implications o f the diagnosis, perceived consequences o f having h igh b lood l ip id levels, and whether or not they experienced related symptoms. Personal circumstances, such as their social role and/or age or life-stage, also influenced h o w much some informants became concerned about the condit ion. Be ing Diagnosed Be ing diagnosed w i t h high b lood l ip id levels influenced the informants dif ferently. Fo r some, i t was a scary experience: I was scared first, i t fr ightened me because they had so many deaths and that in the family, and because I had these young kids and I thought " O h Chr is t " (deep sigh) " I ' m going to be dead and they ' l l go th rough the same th ing I wen t th rough w i t h a dead old man and then you g r o w up w i thou t a father" k ind o f th ing. A n d so that, that th rew a f r ight into me. (Bruce) I n contrast, other informants v iewed the diagnosis as a good experience because i t made them aware that they were not as healthy as they thought they were and i t p rov ided an incentive to do something about i t o r was enough to make them th ink about being healthier. F o r example: I found that i t ' s interesting in that I guess I was overweight, but I d idn ' t really ever consider mysel f really heavy. A n d (pause) I ' m glad that I discovered that because n o w I can do something about it. ... A n d I have lost weight , so f r o m that perspective I guess i t 's certainly been a good experience. (Richard) 124 RESULTS Finally, some informants indicated that their doctor 's attitudes inf luenced h o w seriously they attended to the diagnosis and h o w much they became concerned about having the condi t ion. Fo r example: H e came back and to ld me that i t was high and w e should do something about i t , but he d idn ' t want to resort t o drugs. There were medicines ou t there that he k n e w about but he said " W e l l let 's not get into that un t i l y o u absolutely have t o " ... so that went on for a bit unt i l I moved here and found a n e w doctor here w h o t o o k my b lood again, 'cause I to ld h im about m y h igh cholesterol, go t the results back, but his response was tota l ly different. H e was quite alarmed and he said " W e l l w e got to do something about th is . " (Kev in ) Unfor tunate ly , doctors ' attitudes were not always helpful. D u r i n g the telephone interv iew Grace reported that, after nine years at the L i p i d Clinic, her doctor said he d idn ' t need to see her anymore and sent her GP a letter saying that w i t h w o m e n y o u d o n ' t have t o w o r r y as much about heart disease. However , when she saw a different specialist f o r another prob lem and to ld h im about having high cholesterol, he " f l ipped o u t " and t o l d her t o have her cholesterol checked again. H e r GP's response was " d o n ' t w o r r y about i t . " Consequently, Grace was confused and wondered w h y she was wor ry ing about her cholesterol i f her doctor d id not th ink i t was important. N o w she wonders "unless I ' m really sick, w h y even be bothered." I n general, the informants ' reactions to being diagnosed w i t h h igh b lood l ip id levels (summarized in Append ix I ) had implications fo r the actions they t o o k f o l l o w i n g the diagnosis. Fo r many informants being diagnosed w i t h h igh b lood l ip id levels increased their mot iva t ion to make changes to health-related behaviours. Fami ly H is to ry A s indicated in Table 4.2, most informants had a fami ly history o f heart disease and/or 125 RESULTS high b lood l ip id levels. Several o f these informants indicated that having a fami ly h istory made them wor r i ed or concerned about the diagnosis: B u t because I had a strange history w i t h the fami ly and everybody popp ing o f f and there's heart attacks all over the place I was very concerned about i t , so I made a fair ly concerted effort. (Bruce) W e l l I was quite wor r ied about i t because m y m u m had h igh cholesterol and h igh b lood pressure, wh ich I have, and she died quite, I th ink, very young. A n d her who le fami ly is dead. ... W i t h M u m ' s family, she had 2 brothers and a sister, and they died- Her sister died at 42 and her brothers were, I ' m no t qui te sure, 60 or something. ... They all died o f heart ... so there's bad heart all the w a y through. (Claudia) I t was not clear whether all o f the informants w i t h a fami ly history were more concerned because o f having a fami ly history. Grace and V ic to r ia were the only informants w i thou t a fami ly history o f heart disease. Wh i le i t was not clear whether no t hav ing a fami ly h istory inf luenced Grace's ou t look about being diagnosed, i t was apparent that V i c t o r i a was very resentful that she had high b lood l ip id levels because she did not have a fami ly history. M y mother, w h o has had T W O bouts o f var ious kinds o f cancer, is al ive and d o w n in False Creek. M y brother is in Toronto . M y sister is in England. A l l m y grandparents are dead. N o n e o f them so far as I k n o w had any sort o f l ip id problems W H A T SO E V E R wh ich makes me feel V E R Y injured. I mean cancer and allergies and migraine, wel l that 's fine, i t goes th rough our fami ly, but this is not fair, definitely not fair. (V ic tor ia) I jus t th ink i t ' s darned unfair that i t should happen to M E . W H Y ? N O B O D Y I N M Y F A M T L Y has (pause) A n d so " S O M E B O D Y ' S M A D E A M I S T A K E . " ... D o y o u hear that God? (V ic to r ia ) Since very few informants d id not have a fami ly history o f heart disease or h igh b lood l ip id levels very l i t t le can be said about the implications o f not having a fami ly history. Impl icat ions o f Diagnosis and Resentment A f te r being diagnosed, all o f the informants recognized the importance o f mak ing changes to one or more health-related lifestyle behaviours. ( I t should be noted that 126 RESULTS recogniz ing the need to make change did not always translate into actually mak ing those changes.) Some informants expressed resentment about having h igh b lood l ip id levels because i t meant that they had to modi fy health-related lifestyle behaviours, be aware o f h o w they treated their bodies, and/or " w a t c h " o r th ink about the foods they ate. I feel i t ' s k ind o f unfair that i t only hits a certain amount o f the populat ion. Some people can eat and dr ink whatever they want , whenever they want w i t h not w o r r y i n g about what happens blood-wise. Maybe in the long run on overal l health i t affects them, but you w o n ' t k n o w that unt i l y o u ' r e 70. Whereas other people l ike myself, i t happens ... and then you ' re forced t o be aware o f h o w you ' re supposed to be treating your body. A n d yeah there's a lo t o f resentment there 'cause as I said way back on the other side o f the tape there, i t was l ike the stuf f that I tend to l ike happens to be bad fo r me. A n d n o w I can' t have it. Or, we l l I can' t say I can' t have it, I shouldn ' t have it, 'cause I do ... once in a whi le. B u t sure yeah there's some resentment there. Absolutely. I can see my gir l f r iend, and she's just the opposite o f me. She has no prob lem whatsoever w i t h cholesterol so she can eat but ter o n toast and she can put all kinds o f butter on her potatoes or whatever, i t doesn' t matter. ... I w i sh I d idn ' t have to ... wa tch what I eat. (Kev in) Steve said being diagnosed did not bother h im because he had "a lways been a very pragmatic and pract ical person and .... could always deal w i t h problems" and so he " d i d n ' t get alarmed or terr ib ly disappointed or do any o f this ' W h y me' s tuf f or anything o f that nature" H e recognized i t as jus t another th ing and got on w i t h life. However , w h e n asked about any benefits he had experienced as a result o f making changes he to ld the f o l l o w i n g j o k e : Y o u ' v e reminded me o f that j o k e about the g i r l at the Salvation A r m y rally. A n d she's invi ted to speak (laughing) and so she tells the story that she used t o run around w i t h men and dr ink and dance and do all o f those things and then she jo ined the Salvation A r m y , and n o w all she does is stand there and beat this damn drum, ( laughter) A n y w a y I th ink you see the parallel. (Steve) The j o k e indicated that Steve was somewhat resentful about having to make changes. Wh i le the importance o f other considerations gave some informants sufficient reasons t o overcome their resentment and make changes, several struggled w i t h the idea that they 127 RESULTS could not lead their lives w i thou t having to always th ink about what they were do ing. M o r e o n this top ic is presented later in relat ion to Finding a Balance. Perceived Consequences I n addi t ion to the implications o f having h igh b lood l ip id levels, informants were aware o f the negative consequences o f the condit ion. M o s t informants demonstrated an understanding that high b lood l ip id levels meant there was "excess fat in the arteries" w h i c h could result in " th icker more viscous b lood , " and the c logging or nar rowing o f the arteries. Anne added that nar rowing o f the arteries reduced the b lood f l o w t o the heart. Some informants also knew i t was better to have less o f the L D L - C or " the bad cholesterol" because i t c logged the arteries and more o f the H D L - C or " the good cholesterol" because i t helped clean up the b lood. Informants were also aware o f the longer- term consequences, such as experiencing angina, having a heart attack or stroke, and dying, I d o n ' t l ike h igh cholesterol. I t bothers me, and that comes, stems back to M u m . She had angina and ... I thought " O h h h I don ' t wan t that . " Every t ime y o u go up a l i t t le t iny hi l l she had to put a glycerin tablet under her tongue. A n d I thought " O h no, I don ' t want that ." So that 's - I don ' t l ike h igh cholesterol. A l though I k n o w they' re not sure about what i t does, but I can keep i t off. I ' m not tak ing chances. (Claudia) A t t imes, k n o w i n g more about the consequences o f h igh b lood l ip id levels resulted in the informants being more concerned about the condit ion. For example, Anne was not wo r r i ed about having h igh b lood cholesterol unt i l she found out more about the consequences o f the condi t ion: I wasn ' t terr ib ly wor r ied about it. I t d idn ' t sort o f (pause) mean a who le lot. U n t i l , as the years went by you started reading more about h o w H I G H r isk fo r heart attack and stroke one becomes i f one has high, has a history o f h igh cholesterol and then I started t o l o o k at i t from that po in t o f v i e w and became very concerned, very conscious that I S H O U L D t ry and get m y cholesterol down . (Anne) 128 RESULTS I n contrast, other informants were not concerned even w h e n they k n e w about the consequences o f h igh b lood l ip id levels. For example, a l though V i c t o r i a recognized the consequences o f the condi t ion, she did not want to accept the diagnosis and i t seemed l ike she t r ied t o deny that she had h igh b lood l ip id levels. I M E A N I T ' S N O T F A I R . I accept the allergies, and I accept the migraines, and I accept (sigh) the l ikel ihood that I ' l l get cancer, but that came out o f left f ie ld and i t ' s not fair ( laughing) i t 's not what was on m y schedule. ... (pause) N o t at all. I mean definitely not fair. (V ic tor ia ) Overal l , k n o w i n g something about the consequences o f the condi t ion contr ibuted t o the extent that most informants were concerned about it. Related Symptoms Final ly, the presence or absence o f related symptoms, such as angina or atherosclerosis, inf luenced whether or not some informants became concerned. F o r example: I was paranoid about everything. W o r r i e d about eating anything. Even i f i t had a L I T T L E bi t o f fat. ... A n d then o f course at that t ime I had pains in m y chest too , wh ich after T H E Y left, we l l then you sort o f get not so wor r ied . (Grace) A n d m y cholesterol levels at that t ime were high, but the results o f m y angiogram and so on d idn ' t show any blockage o f arteries or anything, and I k ind o f d idn ' t take the cholesterol issue terr ibly seriously at that point. A n d I had stress tests and so on over the fo l lowing few years and the results were always fair ly good f r o m that. (Ma t t ) Indeed, i f signs o f C H D d id not appear, the degree o f concern about the condi t ion sometimes diminished over t ime as informants learned to l ive w i t h the condi t ion and incorporate i t in to their lives. Overal l , the in format ion above identif ied some o f the factors w h i c h inf luenced the in formants ' degree o f concern about having high b lood l ip id levels wh ich , in tu rn , inf luenced the l ike l ihood that they became mot ivated to modi fy o r maintain aspects o f their l ifestyle. I n 129 RESULTS general, those w h o were more concerned were also the ones w h o were more mot ivated to make changes and maintain those changes. Some informants became less concerned about their b lood l ip id levels as t ime passed, however, they were sti l l mot ivated t o mod i f y or maintain aspects o f their lifestyle because they were concerned about their weight , fitness level o r overal l health. Finding Personal Meaning Establishing mot iva t ion to make changes toward healthy eating behaviours and maintain those changes was also influenced by the extent t o w h i c h the informants developed goals o r found personal meaning in what they were doing. A n d sort o f jus t have an objective in your mind as to what you ' re t ry ing to reach . . and be mot ivated towards reaching that. I th ink being mot iva ted is really important t o reach that objective. Cause someone can tel l y o u y o u ' v e go t h igh cholesterol, but unless i t ' s really important t o y o u t o do something about i t they could ... ta lk ' t i l they ' re blue in the face and you ' re not go ing to do anything about it. (Janice) F o r some informants, the chance o f reducing or stabilizing b lood l ip id levels and avoiding "calamit ies" such as heart attacks and strokes was sufficient t o mot ivate them t o make changes and maintain those changes over t ime. For example, Claudia was very determined to make changes because o f her strong family history and because she k n e w wha t her mother went th rough as a result o f having h igh cholesterol. I n contrast, some informants found target ing their l ipids was an abstract concept and were mot ivated by other more concrete or tangible benefits o f dietary modi f icat ion and/or increased exercise, such as we igh t loss (and fo r some, being able to wear nice clothes), increased physical condi t ion ing, and/or an improvement i n overal l health (wh ich encompassed feeling better, l ook ing better, being able to do the activit ies one wants to ) . 130 RESULTS A n d to me the cholesterol 's almost an adjunct k ind o f an incentive to me. The physical condi t ioning, the feeling better because o f better physical condi t ion ing, I th ink , is almost as much o f an incentive t o me. The cholesterol is i n some ways a bi t o f an abstract th ing, but the physical feeling o f being in better condi t ion is a noticeable incentive to me. ... A n d so i t ' s a general health improvement th ing and the cholesterol is bo th a mot ivator and a g o o d side-effect o f the improved condit ion. ( M a t t ) B u t I th ink I wanted my health to be better and I wanted to feel better and I W A N T E D to get nice clothes and to look nice. (Janice) F o r Anne, these other benefits helped to make the change process more reward ing and more attractive. They also provided informants w i t h feedback w h i c h they could evaluate fo r themselves to k n o w whether what they were doing was making a difference. Overal l , finding personal meaning fo r making behavioural changes depended on each in formant 's desire to achieve any one or more o f these outcomes. F o r a f e w informants there was no evidence in the data that they had developed goals or found personal meaning in what they were doing. Given the detailed and in-depth nature o f the interv iews i t is doubt fu l whether this important aspect o f becoming mot iva ted w o u l d not have been ment ioned had i t existed. Perce ived A b i l i t y T o M a k e Changes The informants ' mot ivat ion also depended on whether the changes seemed "doable . " Three factors seemed to influence h o w l ikely the informants thought they could make the necessary changes: their starting point, rate o f change and previous experiences. Ano ther factor fo r some informants was the bel ief that their abil i ty to make changes diminished w i t h age; consequently, they were mot ivated to make changes n o w whi le they sti l l could. . . .while I hadn' t had any further angina problems or heart problems generally i n that m y stress test results have been good, I figured that at 46 i t was about t ime t o th ink seriously about doing something about i t because I th ink i t gets more di f f icul t every year you get older and the worse your shape gets. ( M a t t ) 131 RESULTS "Star t ing po in t " was the te rm used to describe where informants were o n the cont inuum between unhealthy and healthy eating behaviours before they started mak ing changes. Several informants w h o were closer to the healthier end o f the cont inuum found i t easier to either make changes or maintain previous behaviours. Fo r example: W e l l w e have A L W A Y S in this house never eaten fat, l ike w e have breast o f chicken the leanest meats. A n d w e ' v e doing that f o r years, even before I started, so I d idn ' t have to make any change about that sort o f th ing. ... A n d w e ' v e always had skim mi lk in our diet. (Janice) Other informants w h o were init ial ly closer to the unhealthy end o f the cont inuum predicted that i t w o u l d be di f f icul t t o adopt healthy eating behaviours. For example: W h e n y o u start o f f the goals are really, really di f f icul t t o obtain. A n d they ' re SO far away from where you are today that i t ' s just "Phhh, not a hope in he l l . " W h e n I started losing weight, the idea o f losing the 40 or 50 pounds i t seemed t o me, phhh, just a pipe dream. ( M a t t ) A t the same t ime, start ing closer to the unhealthy end was sometimes a g o o d th ing. Fo r example, M a t t said being so far the other w a y made i t easier fo r h i m t o make changes because i t was fair ly obvious what he had to change. I t was very easy fo r me to identi fy the fact that I was having a H U G E amount o f fat intake everyday ... So pret ty readily identif iable that I probably had 3 or 4 t imes the amount o f fat intake per day that I should have had. So i t required pret ty, as I say, aggressive action on my part t o - O n the other hand, in some ways easy because i t was so identifiable. I f I had already been o n a fair ly sparse diet ... i t w o u l d have been very di f f icul t t o identi fy what I cou ld do, w i t h i n reason, to make a significant change to my intake level. Fo r me, i t was dead easy, r ight. Oops ( th row ing imaginary m i l k away) no more chocolate mi lk . Oops no more French fries. (Ma t t ) Overal l , start ing closer to unhealthy end o f the scale was either a helper because i t was easier to target what behaviours required modif icat ion, o r a barrier because previous f o o d preferences may make the required changes seem unacceptable. Similarly, start ing closer to healthy end o f the cont inuum was either a helper because previous f o o d preferences made the 132 RESULTS required changes seem more acceptable, or a barrier because i t was harder t o determine what behaviours could be modi f ied. The second factor wh ich seemed to influence perceived abil i ty to make changes was the rate o f change or h o w quickly informants changed their behaviours. Wh i le a f e w informants were able t o make drastic changes and maintain those changes over t ime, most o f them found i t easier to make l i t t le changes wh ich involved making small progressive steps and having the small changes add up over t ime. I t ' s st i l l I th ink, the ta lk that I had w i t h (the) doctor ... was really g o o d t o pu t everything in perspective. A n d he just said " W e l l , w e ' l l call y o u back jus t to ... remind y o u about things. A n d we want y o u to t ry and make these l i t t le changes so that they ' re done unconsciously almost ... they 've become part o f y o u r l i fe and w e don ' t want you to feel you have t o go out and do diet s tu f f because i t doesn' t w o r k . A n d w e want you to just w o r k o n this l ifestyle. A n d lifestyle changes take a lot o f t ime." (Tracy) Fo r some, this approach helped make changes seem more "doable , " wh i le fo r others i t min imized feel ing l ike they were being deprived or missing out and helped them balance mak ing changes w i t h enjoying life. I t jus t builds, the l i t t le changes that you make that you don ' t really realize that you , you ' re making. Y o u T F f f N K about them, but y o u don ' t k n o w that they ' re affecting you that much. A n d then you make another l i t t le change and the other one's stil l is there and then suddenly you ' ve made 10 l i t t le changes and as a, as a group they mean something. That l i t t le bi t o f watch ing fat, that l i t t le b i t o f extra walk , 3 more blocks a day, o r 3 more b locks a week, and one less cup o f coffee w i t h mi l k in it - just those l i t t le things over a per iod o f t ime make a difference. (Nancy) Typica l ly the informants w h o made more drastic changes to their eating behaviours sti l l only d id so w i t h respect to one or t w o food components. Fo r example, M a t t only targeted the fat and saturated fat i n his diet, whi le Richard was concerned about fat and cholesterol. 133 RESULTS Finally, previous experiences w i t h making changes inf luenced in formants ' perceived abi l i ty t o make changes. Nancy reported making changes was becoming easier because she had succeeded in making some changes. That is, some o f the changes had become part o f her day-to-day rout ine (they were incorporated into her l ifestyle) and she per formed the new behaviours unconsciously. Therefore, these new behaviours were not d i f f icu l t anymore, and th ink ing about mak ing new changes was less daunting and required "less contemplat ion pr io r t o mak ing changes." Fo r her, i t was grat i fy ing t o k n o w that "changes can be made and they ' re easy." E s t a b l i s h i n g a " P o s i t i v e " A t t i t u d e This aspect o f becoming mot ivated was not identif ied dur ing the main data analysis per iod and was not included on the mai lout summary sent t o the informants. However , several informants identi f ied that i t was missing and were clear about its importance dur ing the telephone interviews. Essentially, having a posit ive att i tude was " k n o w i n g that wha t you ' re do ing is good fo r y o u " or not being bothered about having to make changes. Steve said the " b i g t h i n g " is t o "have the att i tude that i t 's necessary to d o " (i.e., be resolved that changes are necessary) and "stay posi t ive" or have a posit ive mental att i tude. H e thought " i f y o u are negative then y o u w i l l probably fal l o f f because you feel you ' re depr iv ing yourse l f and you l o o k f o r faul ts . " Similarly, Tracy believed feeling l ike y o u were being depr ived or that y o u had to eat " c r u m m y f o o d " is not a helpful att i tude; instead she thought " i t is better to be posit ive about changes and what you ' re eat ing." Past O u t c o m e s Final ly, fo r some informants their degree o f mot iva t ion was inf luenced by past 134 RESULTS outcomes or the extent to wh ich feedback provided evidence o f desirable outcomes and/or enabled them to evaluate their efforts w i t h respect to the benefits achieved. Past outcomes indicated whether they were engaging in enough healthy eating behaviours o r mak ing enough changes to br ing about desirable results. A s mentioned above, achieving desirable results not only refers t o reducing or sustaining b lood l ip id levels and avoiding "calamit ies" such as heart attacks and strokes, but also to losing weight (and fo r some, being able to wear the clothes they wanted t o ) , enhancing physical condit ioning, and improv ing health (as demonstrated by feel ing better, l ook ing better and being able to do the activit ies one wants to ) . Therefore, a l though some informants were uncertain about whether they w o u l d even be able t o achieve desirable b lood l ip id levels, most used other more concrete or tangible outcome measures to judge fo r themselves whether what they were doing was making a difference. B o t h undesirable o r desirable past outcomes prov ided a feedback loop that inf luenced the extent t o w h i c h informants made new changes and/or maintained the ones they had already made. The inability to achieve desirable outcomes inspired some informants t o " t r y harder" by mak ing more changes. Fo r example: Just the constancy o f my cholesterol not changing. Every t ime I wen t i n and I ' d th ink " W e l l this t ime i t ' s got to better" and then I get the result and i t is no better. I t f inal ly ... go t me that I have to get more drastic w i t h the changes I ' m mak ing (Anne) I n contrast, the inabil i ty to achieve desirable results had the opposite effect o n other informants. These individuals chose to "g ive u p " and stopped mak ing dietary changes since they were not receiving a return fo r their efforts. W h e n you ' re used to just eating what y o u want , i t ' s k ind o f t o u g h t o be shocked w i t h this news and you got to switch everything around. A n d then Y O U D O T H A T , y o u actually make the effort t o do i t and then noth ing changes and then y o u get sort o f depressed about what you ' re doing. Y o u ' r e 135 RESULTS l ike " A a h h what the heck, that d idn ' t w o r k . " ( laughing) So I might as we l l jus t eat what I want. (Kev in) Achieving desirable outcomes also had varying implications fo r dif ferent informants. Some were inspired t o continue the cycle o f making more changes because they k n e w there was sti l l r o o m fo r improvement and/or believed they w o u l d be able to achieve even more desirable outcomes. Fo r example, dur ing Kev in ' s f irst interview he reported that he had obtained some desirable outcomes fo r the f irst t ime after he quit smoking and began tak ing l ip id- lower ing drugs, therefore he believed he could achieve even more desirable outcomes by mak ing even more changes. (The fact that the results went d o w n this t ime) ... kept me from sl iding back t o m y o ld ways. I t ' s l ike " Y e a h we l l n o w I ' m seeing results." N o w that gives me hope to , maybe lower i t even more by maybe start ing exercising. Tha t ' s something I don ' t do. So maybe I should do that. A n d maybe instead o f let t ing m y guard d o w n l ike w e were ta lk ing before, paying more at tent ion and t r y ing t o eat even better. T ry ing t o get into the vegetable th ing. W h i c h is go ing to be hard, but I w i l l try. (Kev in) I n contrast, other informants al lowed themselves to relax and return t o some o f their previous eating behaviours because they had achieved desirable results and/or were coming close to reaching their goals. I n the last 4 months I 've gained some o f m y weight back again. A n d that 's because I ' m al lowing.. . N O W when you 've reached a goal or almost reached there, y o u begin to do things that you d idn ' t do before. L i k e y o u w o u l d let a l i t t le more sugar creep into your diet. Y o u ' d let a l i t t le more fat creep in to your diet. Then you say "Okay, i f i t rains I w o n ' t w a l k today, but I ' l l go t o m o r r o w . " A n d I never al lowed that in m y f irst year. I was really, really strict w i t h myself. B u t when you get to a point then y o u th ink " W e l l a l i t t le bi t is all r igh t " ... I ' m so close to my objective I ' m cheating more. So I don ' t have the same w i l l -power as I d id back then because I k n o w n o w ... i t doesn' t take much t o lose this last five pounds (Janice) Final ly, other informants continued w i t h the same level o f behaviour by maintaining the changes they had made w i thou t making new ones because they were satisfied w i t h the 136 RESULTS outcomes they had achieved. For example, M a t t was not mot ivated to make any more changes because he assumed the returns or outcomes o f mak ing more changes w o u l d not be m u c h better than those he had already achieved. I start t o feel at a certain point that i t becomes a diminishing returns issue o f get t ing that last 2 5 % as i t were. W h e n I see my condi t ion improve, and m y we igh t coming down, I don ' t feel much incentive to go that extra 2 5 % because I feel I ' m accomplishing m y pr imary goals w i t h the level I ' m at. A n d so I don ' t have a huge incentive to really beat on that last l i t t le bit. I t feels, as I say, l ike a case o f diminishing returns. ... A n d so i f you get to a point where there's no enjoyment in your l i fe then ... why? ( M a t t ) Thus, feedback enabled the informants to assess whether their efforts were w o r t h i t in terms o f the benefits they achieved. Each cycle o f making changes and obtaining feedback prov ided them w i t h a new oppor tuni ty to evaluate their outcomes and efforts and to make decisions about their behaviours; consequently, evaluations and decisions changed over t ime as new outcomes presented themselves. Overal l , becoming mot ivated was an important aspect o f in i t iat ing and maintaining the process o f dietary change. The informants w h o appeared less mot ivated made very few changes or d id not maintain the changes they had made, wh i le the informants w h o seemed more mot ivated made more changes and were more l ikely to maintain those changes over t ime. The informants ' level o f mot ivat ion was not static, but changed over t ime in response to changes to one or more o f the factors described above, and probably in response t o other factors not identi f ied by this study. 4.4.1.2. Reso lv ing T o M a k e Changes The extent t o wh ich the informants were resolved to making changes also inf luenced whether they ini t iated and/or maintained the change process. The importance o f the concept 137 RESULTS in terms o f in i t iat ing the change process was made evident by M a t t ' s comment: W h e n I had a cholesterol test this year, in January o f this year the results were k ind o f str ik ingly high. A n d so I pret ty much resolved to do something about i t and proceeded to do so. ( M a t t ) H e " jus t made a f i r m decision t o do something fair ly drastic." Other in formants also started the change process after recognizing or making a conscious decision that i t was something they needed to do. I t w o u l d be M a r c h of '94 that I 'd started to say " H e y I ' m the only one that can t u r n m y l i fe around as far as feeling physically we l l and i t ' s up t o me. " A n d that meant go ing from a rather sedentary lifestyle to a very active one. (Janice) In formants w h o were not resolved about changing their eating behaviours ta lked about "cheat ing" and "sneaking f o o d " when family members were not around. 4.4.1.3. Persona l C i r cums tances Final ly, several contextual factors or personal circumstances inf luenced whether or not in formants were resistant o r w i l l i ng to init iate and/or maintain the change process. These factors included upbr inging, l iv ing situation, social role, l ife-stage and gender. I n terms o f upbr ing ing, several informants reported that some eating behaviours were di f f icul t t o change because o f h o w they were brought up. Janice had to watch her carbohydrates because she recognized that she had a weakness fo r carbohydrate foods because that was wha t she was brought up on and " i t ' s a habi t . " V ic to r ia also found i t d i f f icul t t o make changes because o f her upbr inging. She referred to cook ing "Eng l ish" and the bel ief that "Engl ish people tend to roast or fry quite a lot more . " Furthermore, she recounted a story about her " reg imented" ch i ldhood to explain w h y she was resistant to making changes: W e l l f o r one th ing, I don ' t l ike anybody tel l ing me what I ought o r ough tn ' t t o do. I t was all the t ime I was g row ing up in board ing school, I had- T h e n i t wasn ' t so much what I hadn' t t o eat, i t was what I H A D t o eat. F ish fo r 138 RESULTS example, w h i c h I loathe and A B O M I N A T E . A n d I started o f f at a convent and not only d id y o u have to eat it, but i f you D I D N ' T eat i t y o u had to go in to the chapel and explain to Jesus w h y y o u were "Pushing thorns in to his head." A n d this at 5 can have a very S T R O N G impression on you . ... This was done t o make y o u eat your f ish and the result is that I do not eat fish, as I t o l d the diet i t ian I see w h o to ld me cheerfully that " W h i t e fish was such a G O O D th ing to eat." I said " I ' m sure i t is, but not for me." (V ic tor ia ) Wh i le other informants contrasted h o w they ate n o w to the foods or type o f diet they ate w h e n they g rew up, many did not specify that their previous habits made i t more di f f icul t f o r them to change. They simply used past eating behaviours to i l lustrate h o w they had changed. Ano ther personal circumstance that pr imari ly influenced the in formants ' efforts to adopt healthy eating behaviours was their l iv ing situation and whether their fami ly and friends prov ided a support ive or unsupport ive environment. The informants l i v ing o n their o w n generally felt i t was easier to make changes at home because they were able to only keep appropriate foods in the house and did not have to w o r r y about the needs o f other people. A n d sometimes I get a craving fo r something, we l l i t ' s not there. A n d I l ive m y o w n w h i c h is- I k n o w i f you ' re marr ied w i t h chi ldren and that and y o u have a husband w h o likes desserts, you can't get away f r o m it. B u t I can get away from it. Be ing single I th ink I ' m able to . I do m y o w n cook ing and I jus t don ' t buy it. (Claudia) Hav ing a support ive spouse and/or family also helped many informants make changes, especially w h e n they made comments such as " W e l l you shouldn' t have that " o r " M u m m y , y o u ' r e not supposed to eat that chocolate bar" o r asked questions such as " I s that g o o d fo r y o u ? " Spouses and other family members were also support ive w h e n they ate the same appropriate foods as the informants d id and did not br ing inappropriate foods in to the house. I n contrast, some informants said i t was more dif f icult t o init iate o r maintain the change process because their spouse and/or family wanted certain inappropriate foods or brought these foods in to the house. Janice emphasized the importance o f having the support o f others 139 RESULTS and indicated the di f f icul ty o f t ry ing to maintain changes in an unsupport ive environment. I th ink i f y o u have support ive people in the house w h o d o n ' t g o out o f their w a y to sabotage you. I t ' s very easy to be sabotaged. Y o u can go ou t fo r dinner t o some people's house and they k n o w you ' re o n a diet and they ' l l deliberately make something really ... y o u know. So y o u need support ive fr iends and fami ly w h o are there to k n o w that you ' re t ry ing to do something fo r yourse l f and be supportive. ... L i k e my husband eats what I am, but lets say he 'd l ike to have dessert and he eats the dessert i n front o f me. I mean that, that just makes i t diff icult. ... So I th ink they have to go eat the dessert at another t ime when you ' re not having dinner or something. I jus t th ink that y o u need the support o f your family. ... So they ' re helping you . They ' re not t r y ing to sabotage you k ind o f th ing ... because they want these things. ... So y o u need t o have some k ind o f support ing, support there from the fami ly members, especially i f you have a lot o f weight to lose . . otherwise i t makes i t very di f f icul t . (Janice) Several informants increased the support they received from others by t ry ing to educate them about appropriate and inappropriate foods, and healthy eating behaviours. T w o other personal circumstance that influenced informants ' efforts t o init iate o r maintain the change process were their social role and life-stage. Gender seemed t o also play a role w i t h respect to these factors. The social role o f being a parent made some informants more aware o f the need to make and maintain changes so they w o u l d be around longer fo r their chi ldren. Fo r example: So I th ink jus t the informat ion has finally got ten th rough and I ' m more conscious o f i t . . . and maybe the desire's greater. I turned 40. I have a y o u n g chi ld, I ' ve got to be here fo r him. (Nancy) I n terms o f informants ' gendered social role, the t w o mothers o f young chi ldren (Tracy and Nancy ) were more l ikely to compromise their needs w i t h respect to those o f their families. Wh i le they were of ten able to combine their needs w i t h the needs o f their chi ldren and husbands, they indicated that sometimes they over looked their needs in order t o prepare foods their families w o u l d l ike. 140 RESULTS M y init ial react ion was to just go in clear out the cupboards ... and " T h i s is h o w w e were go ing to do things from n o w o n . " A n d that lasted probably a month . A n d then reality k ind o f set in and I had to balance o f f things, l ike t o do w i t h the kids and m y husband. Because I ' m the one w h o makes the meals and does all the grocery shopping and whatever. A n d they jus t weren ' t interested I th ink in sort o f doing these strictly healthy things or wha t I thought I was do ing to be really healthy. So that 's w h y the granola bars k ind o f came back on the shelf and that 's when w e k ind o f relaxed things a l i t t le ... and w e have puddings and things, but that 's sort o f the compromise between wha t the kids really, they can handle versus what I th ink should be in the house. (Tracy) The only father w i t h young children at home (Bruce) seemed to separate his needs from his chi ldren's needs in that when he prepared dinner he catered to his o w n needs in addi t ion to accommodat ing his family. Furthermore, he stated his k ids ' f o o d preferences were not t o o much o f a prob lem yet because they were stil l young and did not br ing inappropriate foods in to the house. Similarly, other informants whose chi ldren no longer l ived at home reported that mak ing and maintaining changes was easier n o w because they d id not need to have certain inappropriate foods in the house. There were a f e w other indications that gender influenced in formants ' efforts t o make and maintain changes. Several o f the married men w h o did not play a large ro le i n preparing meals o r shopping fo r f o o d indicated that they relied on their wives t o prov ide appropriate foods. F o r example, Ol iver said i f his w i fe was to "s l ip " and "b r ing the w r o n g foods home, " he w o u l d eat them. Tracy ( l ike most o f the other female informants) had a history o f diet ing to lose weight . She said i t was always something she had in the back o f her head and commented that " w o m e n are more conscious about weight than men . " Tracy 's remarks suggest that social norms and expectations on w o m e n to wa tch their we igh t may make i t easier fo r w o m e n to modi fy their eating behaviours. Instead o f referr ing t o past we igh t concerns, t w o male informants characterized themselves by the type o f foods they used to eat. 141 RESULTS K e v i n was a "beer and pizza k ind o f guy " and M a t t was a "hamburger w i t h cheese k ind o f guy . " K e v i n also said that "guys l ike to have burgers and fries" and believed that " w o m e n eat l ighter " and "mos t w o m e n tend to eat better i f they can." Whi le he noted that the w o m e n at w o r k ate salads, he said he could not "survive on a salad" because " tha t ' s not me . " Kev in ' s remarks suggest that social norms and expectations on men to be less restr icted about what they eat may make i t harder fo r men to modi fy their eating behaviours. Interest ingly, there also seemed t o be gender differences w i t h respect to h o w informants chose to proceed i f they d id not achieve desirable outcomes after making changes. The w o m e n were more l ikely to " t r y harder" by mak ing more changes, whi le the men were more l ikely t o "g ive u p " and re turn t o previous eating behaviours. A s explained above, age influenced some informants to make or maintain changes because they believed their abil i ty to make changes diminished w i t h age and they should make changes n o w whi le they stil l could. Another aspect o f life-stage that inf luenced informants included whether they were ret ired or not. Several informants indicated that they found i t easier to make dietary changes or exercise more because they were ret i red and therefore had more t ime available to them. Overal l , the main dr iv ing factors wh ich helped informants init iate and maintain the process o f dietary change were becoming mot ivated and resolving to make changes. Be ing concerned about having h igh b lood l ip id levels, finding personal meaning or a mot i ve f o r mak ing behavioural changes, perceived abil ity to make changes, and past outcomes were all very important mot ivat ing factors. Hav ing a posit ive att i tude about mak ing changes also helped some informants actively make changes to their eating behaviours. Several personal 142 RESULTS circumstances, such as upbr inging and l iv ing situation, also served as dr iv ing factors. Whether fami ly o r fr iends prov ided a support ive or unsupport ive environment was a part icular ly impor tant aspect o f informants ' l iv ing situation. The presence or absence o f these dr iv ing factors determined the degree to wh ich informants were resistant or w i l l i ng t o make certain changes and maintain those changes. 4.4.2. Cycles o f M a k i n g Changes Regardless o f h o w prepared the informants were to make changes, once the process was ini t iated i t involved cycles o f making changes to f ind a balance between enjoying l i fe and mak ing enough changes to achieve desirable diet-related outcomes. Cycles o f sl ipping and get t ing back on t rack also occurred. Finally, the process involved evaluating outcomes and efforts and making decisions about cont inuing or ending the process. I f the process was ended, the f inal outcomes were g iv ing up (Le., returning to o ld eating behaviours) o r maintaining the changes (i.e., adopt ing new eating behaviours). Be fo re explaining the components o f the model i t is impor tant to indicate that the informants were selective about what types o f behaviour changes they made. First, they generally chose t o focus on one or t w o types o f health behaviours, such as modi fy ing their diet, increasing their exercise level, and/or qui t t ing smoking, and not all o f them chose to pr imar i ly focus o n modi fy ing their eating behaviours. Indeed, at the t ime o f the study several informants were either equally or more focused on improv ing their exercise level. Second, w i t h i n the area o f diet modi f icat ion, most informants chose to focus on one o r t w o areas o f eating behaviours. Fo r example, many informants init ial ly focused on reducing the fat in their diet, even though they recognized that there were other things they could do as wel l . 143 RESULTS Some o f the other cholesterol f ighters, l ike maybe the oat bran and s tu f f that don ' t , aren' t fat, those are the ones that I ' m not really conscious o f Y E T I k n o w about the F A T part o f the cholesterol contro l , but I k n o w that there's other dietary ... fibres or the, as I say, the oat bran that I ' m not really famil iar w i t h ... that sort o f non-fat type foods. (Nancy) Similarly, wh i le M a t t recognized there were other changes he could make, such as cut t ing d o w n on his sugar intake or eating more fish, his "single pr ime goa l " was t o eliminate fat generally and saturated fat specifically from his diet. What informants decided to focus o n (e.g., saturated fat versus dietary cholesterol) and the breadth o f that focus (e.g., to ta l fat intake versus intake o f French fries) influenced whether or not enough changes were made in order to achieve desirable outcomes. 4.4.2.1. Finding A Balance A s indicated earlier, finding a balance was the central dimension or perspective w h i c h gave theoret ical and explanatory f o r m to the story o f making dietary changes. A s a whole, dietary change was an experimentation process in wh ich informants experimented w i t h various changes in order to achieve a personally acceptable balance between enjoying l i fe on the one hand and mak ing enough changes to achieve desirable results on the other. I n general, finding a balance was a process o f compromising between enjoying l i fe and making enough changes. A s M a t t said, he was " t ry ing to find something that 's healthy and satisfying and yields results." However , the informants not only experimented w i t h finding changes that were personally acceptable (i.e., t ry ing to find a balance between the recommendations prov ided at the L i p i d Cl in ic and their o w n personal preferences or requirements), but also experimented w i t h the amount o f changes they had to make in order to see returns fo r their efforts. 144 RESULTS The value and meaning given to enjoying l i fe versus the importance or relative weight g iven t o mak ing enough changes (depending on their mot iva t ion to obtain desirable outcomes) determined h o w many changes they made. Some informants found a balance between enjoying l i fe and making enough changes that enabled them to make many changes and/or engage in many behaviours closer to the healthier end o f the scale. They of ten d id not feel deprived w h e n they made changes and perceived that the new behaviours were "reasonable." They also d id not indicate that too much t ime and effort were required to make changes. I n contrast, other informants found a balance that prevented them f r o m mak ing as many changes and/or engaging in as many behaviours near the healthier end o f the scale. These informants of ten felt depr ived or missed foods when they made changes and perceived that the new behaviours were not "reasonable" and/or that too much t ime and effort were required fo r t oo l i t t le i n return. Hence, where informants found a balance had an impor tant impact o n the process o f mak ing and maintaining changes. Shifts in the locat ion o f balance between enjoying l i fe and mak ing enough changes occurred over t ime in response to various changes to one or more o f the factors described above, such as changes in their level o f mot ivat ion, changes in their knowledge and understanding o f the l ip id- lower ing diet, and external influences f r o m the environment (e.g., seasonal differences wh ich require changes in day-to-day patterns). Fur thermore, in formants ' decisions about what changes to make or not make, the value or meaning g iven t o enjoying l i fe, impl icat ions o f changes in personal circumstances (e.g., changes in l i fe-stage), and the perceived value o f making changes in l ight o f the outcomes achieved and efforts required also changed over t ime and influenced where informants found a balance. 145 RESULTS The process o f finding a balance or choosing what behaviours were personally acceptable also helped informants maintain a sense o f cont ro l over their l ives. F o r example, B ruce said i f he always had to th ink about what he should or should not eat he w o u l d feel l ike he was being too control led: Y o u can get t oo k ind o f control led ... and I don ' t want t o l ive that- I d o n ' t wan t t o be th ink ing about what I ' m doing. I don ' t want t o ... have to make judgments f r o m minute to minute to minute to minute. I want t o be able to make a fair assessment, make (pause) one decision or t w o decisions. A n d then have those t w o fundamental decisions affect all those other decisions d o w n the road. So I ' m not H A V I N G to deal w i t h "Should I or shouldn' t I , should I , should I , shou ld . . . " all the t ime. I 've got that f ramework decision o f wha t I ' m shoot ing at and then I don ' t have to T H I N K about i t everyday, every [ incident?]. Because that really, that 's just a pain in the ass. I jus t - W h a t the hell. W h a t w o u l d be the point. ... There are some people I guess w h o l ike to l ive that way, but I have absolutely no interest in it. (Bruce) Enjoying Life The value and meaning given to enjoying l i fe related to qual i ty o f l i fe issues, such as the satisfaction, enjoyment, and pleasure obtained from life. Fo r some informants, enjoying l i fe invo lved not feeling deprived and not feeling l ike they were being control led. I n terms o f eating behaviours, enjoying l i fe fo r these informants involved eating what they l iked to eat, not eating jus t f o r the sake o f prov id ing the body w i t h fuel, not having to eat " c r u m m y " f o o d and not being wor r ied or having to th ink about everything they ate. So i t ' s pret ty easy to ... tu rn o f f things that make your l i fe d i f f icul t o r less enjoyable. A n d you look at i t and y o u say " W e l l , qual i ty o f l i fe 's impor tant t o y o u . " A n d i f y o u feel crappy all the t ime " W h o cares." L i k e this is the th ing, i f y o u get t o the 100% point o f the scale diet and you feel crappy all the t ime w h y bother being alive in the first place. I f you D O N ' T have qual i ty o f l i fe, w e ta lk about that all the t ime, i f y o u don ' t have i t then wha t ' s the point. ( M a t t ) I n general, unhealthy behaviours (such as smoking, dr inking, and eating high-fat foods) were of ten perceived t o be more enjoyable, whi le healthy behaviours required ef for t and were 146 RESULTS thought to be less enjoyable. This meaning o f enjoying l i fe made i t more di f f icul t f o r the informants t o make enough changes to achieve desirable outcomes. A t the other extreme, informants defined enjoying l i fe as being healthy, being able to do the activit ies they want to , or knowing that they were extending their l i fe. F o r example: I ' m go ing to be 58 next month. A n d I see a lot o f w o m e n m y age and ... they aren' t able to go h ik ing or walk ing. Y o u can see them becoming very sluggish in h o w they carry themselves. They ' re gett ing o ld quickly. A n d a lo t o f i t ' s because o f excessive weight and therefore they can' t D O all the things that I enjoy doing. I want to go bicycl ing or h ik ing and shopping ... f o r nice clothes. They can ' t do those things. Maybe they get resigned to that and they g ive up. I don ' t know. Maybe i t 's not important to them. I t ' s important to me. ... I want t o g r o w o ld gracefully. I want to have as many g o o d years as I can and enjoy m y life. (Janice) This meaning o f enjoying l i fe helped the informants make changes because their def in i t ion o f enjoying l i fe was more congruent w i t h achieving desirable outcomes. Some informants defined enjoying l i fe using concepts from both o f these extremes, such as being healthy or being able to do the things they want to and not denying themselves. Regardless o f h o w informants defined enjoying l ife, several informants thought i t was impor tant to be "reasonable" about mak ing changes because the changes they were mak ing were " f o r a l i fe t ime." A s explained above, personal acceptability o f various healthy eating behaviours was related t o in formants ' beliefs about their r ight to choose what they were w i l l i ng to do and the fact that i t helped them maintain a sense o f contro l over their lives. I t also appeared that dif ferent informants found certain healthy eating behaviours more or less acceptable according to the value and meaning they gave to "enjoying l i fe ," h o w mot ivated they were to achieve desirable outcomes and their att i tude toward making changes. Fo r example, those w h o were 147 RESULTS highly mot ivated and had a posit ive att i tude v iewed more changes or behaviours as acceptable and were more w i l l i ng to compromise in order to achieve desirable outcomes. I l ike t o be healthy. I l ike to keep wel l , and so i f changing m y diet is go ing t o make a difference, or i t is recommended, then that 's all r ight w i t h me. (Anne) I f they say " Y o u can' t eat red meat ever again," I ' d say " W e l l fine, I ' l l eat fish and chicken." I don ' t really care that much. (Claudia) Other informants were either less mot ivated to achieve desirable outcomes or were less w i l l i ng to forego the enjoyment they received from certain healthy eating behaviours. Treats f o r me are generally the forbidden ones that I t r y no t t o eat, o r can ' t eat, or I ' m t o l d I can' t eat. B u t you only l ive once so i t ' s no use being miserable jus t eating bor ing stuff. So yeah go fo r it. (Kev in) I ' ve t r ied to sort o f balance o f f h o w much I enjoy the f o o d that I eat and sti l l achieve some goal that I feel is achievable w i thou t compromis ing to the point that there's nothing much o f interest on my plate. ( M a t t ) M a k i n g E n o u g h Changes M a k i n g enough changes to "make a difference" or achieve desirable results was the second key component o f finding a balance. A l l o f the informants were attending the L i p i d Cl inic in order t o find out h o w they could reduce their b lood l ip id levels and reduce their r isk fo r heart disease. Therefore, the underlying purpose o f mak ing changes was to see a difference in their b lood l ip id levels. The amount o f change required by any g iven in formant i n order to see a difference depended on t w o factors. First, as indicated earlier, i t depended on his/her start ing po in t o n the unhealthy t o healthy eating behaviour cont inuum. Second, i t depended o n h o w responsive his/her b lood lipids were to dietary modif icat ions. A s described earlier, some informants identif ied that there was inter indiv idual var iabi l i ty associated w i t h the condi t ion because what consti tuted enough change fo r one person d id not produce desirable outcomes for someone else. Wh i le many informants made 148 RESULTS changes and were able to achieve one or more o f the desirable outcomes l isted above (such as feel ing better, losing weight , or improved physical condi t ioning), not all o f t h e m were able t o lower their b lood l ip id levels, despite making what they thought were enough changes. Fo r these individuals, i t seemed that other factors besides mak ing dietary changes required attent ion (such as tak ing medications, increasing physical act ivi ty, qu i t t ing smoking, losing weight , etc.). F o r a f e w informants, these other strategies d id no t even seem t o help. W e were init ial ly w o r k i n g w i t h , t ry ing to w o r k w i t h diet, and that d idn ' t seem t o help, so I eventually went on medication. ... And (sigh) so I started th is- I t o o k o n M O R E exercise because- A n d more commit ted exercise because even the medicat ion d idn ' t seem to make that much difference. I t w o u l d make a very M I N O R change, but not significant. N o t enough to be comfor table w i t h -... So w e ' v e t r ied increasing the dosage and this k ind o f th ing, but ... I don ' t k n o w wha t i t is about m y system. (Anne) B ruce was also unable to lower his cholesterol, even though he lost we igh t and became extremely physically fit. H e refused t o go o n medications and stopped mak ing changes t o his diet once var ious tests had demonstrated that his arteries were "squeaky clean." I had a goal and n o w I don ' t . N o w m y goal is (s igh ) t o maintain where i t ' s at and to th ink o f that as normal fo r me. A n d i t ' s perfectly l ivable. Every th ing is perfect ly fine. I t ' s not a threat. A n d as long as I don ' t have any coronary occlusions, or y o u don ' t have that plaque bui ld up- These are the things that are actually worr isome. The idea- Y o u could have ten thousand pounds o f cholesterol in your b lood, but i f i t worked , what the hell difference w o u l d i t make. I t w o u l d make no difference at all. (Bruce) I n general, informants w h o seemed unresponsive t o dietary modi f ica t ion started t o th ink their l ip id levels were not under their cont ro l but were h igh because o f genetics o r heredity. F o r example: A t this point I don ' t th ink- I can' t see changing too much. I mean I - Because I ' m beginning to th ink that i t ' s a genetic thing. I f - W i t h all the changes I ' ve made, i t hasn' t made any significant reduct ion in the numbers and ... I ' m beginning to th ink i t ' s genetic and i t ' s just m y body just produces this h igh cholesterol. (Anne) 149 RESULTS For them, making more changes never seemed to be enough. Consequently, they were uncertain that they w o u l d ever be able to achieve desirable outcomes. Anne believed she had made all the changes that were "reasonable" and did not th ink there were any other changes she cou ld make w i thou t losing enjoyment in her l i fe. Instead, she said that she w o u l d have to be content w i t h maintaining the healthy eating behaviours she had established. I n contrast to those w h o seemed unresponsive to dietary modi f icat ion, others were able t o l o w e r their l ip id levels and achieve other desirable outcomes w i thou t having to make as many changes as the less responsive informants. Fo r some, making enough changes meant only doing what they had to i n order t o see a difference. Wh i le they recognized they could make more changes to have even healthier eating behaviours, they d id not see the point o f doing so i f they were already achieving desirable outcomes. Furthermore, they thought making more changes w o u l d reduce the extent to w h i c h they enjoyed life. A s explained above, M a t t referred to this state as a "case o f diminishing returns." K e v i n was also only interested in doing what he had to . W h e n I spoke w i t h h im on the phone a year after the first interview he knew he cou ld probably eat better, however, he was " h o l d i n g " w i t h his eating behaviours unt i l he visi ted the L i p i d Cl in ic again in order t o "see where he was . " H e conceded that i f his l ip id levels w e n t u p he w o u l d have t o change again and do more toward eating better, but unt i l he knew what his l ip id levels were he was not go ing to proceed w i t h any more changes. Other informants placed more emphasis on enjoying l i fe and simply d id not make enough changes to achieve desirable outcomes. Some knew they were not mak ing enough changes, but d id not o r could not do more at the t ime. Others believed they were making 150 RESULTS enough changes (even though it was apparent to me that they were no t ) and could not understand w h y they were not achieving desirable outcomes. These informants also of ten at t r ibuted their h igh b lood l ip id levels to genetics o r heredity and tended t o g ive up making l i festyle modif icat ions. C o m p r o m i s i n g F ind ing a balance or compromising between enjoying l i fe and mak ing enough changes to achieve desirable results was a give-and-take process. However , not only d id informants compromise enjoyment at t imes, but they also compromised making or maintaining changes. Some informants were very aware that making changes was a give-and-take process and had to consciously decide wh ich side o f the balance w o u l d w i n in any g iven situation. A t t imes, all informants reported they sacrificed some enjoyment or compromised in order t o achieve desirable results. For example, Anne reported sacrif icing some enjoyment because she was " sp focused o n eating r ight . " Wh i le informants were no t thr i l led about some o f the compromises they made, they thought i t w o u l d help them achieve their desired outcomes. Fo r example: I t happens when you go to a smorgasbord. Fo r example, I was at a t ra in ing school o n Fr iday and Saturday, and then Saturday night there was a gather ing afterwards and there was finger f o o d and so there was pizza. ... W h i c h is loaded w i t h cheese and fat and so o n ( laughing) and so I d i dn ' t t o u c h the pizza. A n d o f course (mimick ing voice) "Gee that pizza looks pret ty g o o d . " Y o u ' r e hungry and you haven' t had anything to eat dur ing the day ... and the pizza was the best look ing stuf f that was there. There was lots o f r a w vegetables, the carrots and the celery ... A n d all that k ind o f s tu f f and dips and there was frui t . So actually what I had was the raw vegetables and f ru i t and I left the pizza A L O N E . So there's a- I don ' t k n o w what w o u l d y o u call it? A sacrifice. Is that the word? So l ike I sacrificed the fact that I w o u l d have enjoyed to have a piece o f pizza, and I ate the healthy stuff. (Steve) The main differences between informants w i t h respect to compromis ing enjoyment were the 151 RESULTS f requency w i t h wh ich they d id so and their personal concept ion o f " w h a t is reasonable." Some compromised enjoyment often because they were determined to make enough changes in order to achieve desirable results. A s stated above, the informants w h o were highly mot ivated and had a posit ive att i tude were more w i l l i ng to compromise enjoyment in order to achieve desirable outcomes. Others compromised enjoyment w i l l ing ly as long as they were achieving desirable outcomes, but again once the loss o f enjoyment outweighed the gains i t became a case o f "d iminishing returns" and they stopped t ry ing to make new changes. Finally, others compromised enjoyment less of ten because they d id not want to "depr i ve" themselves or feel l ike they were missing out. These distinctions i l lustrate the importance o f having a posi t ive att i tude. That is, recognizing or know ing that "wha t you ' re do ing is g o o d fo r y o u " minimizes feelings o f deprivat ion or that appropriate food is " c r u m m y f o o d . " A t other t imes, all informants reported they compromised w i t h respect to making or maintaining changes in order to enjoy l i fe or make the best o f a situation. Those w h o were determined t o achieve desirable outcomes and felt i t was very important to maintain healthy eating behaviours compromised fo r special occasions or situations in w h i c h they had less cont ro l (recall "mak ing the best o f i t " ) . B y compromising, they min imized the gui l t they may have felt in these situations because they "a l l owed" themselves to enjoy the experience. W h e n Anne was on holidays she ate at a restaurant she normally w o u l d not go to because she k n e w it was jus t f o r one event and it w o u l d help satisfy feelings o f depr ivat ion. Others compromised making or maintaining changes because enjoying l i fe was jus t more impor tant to them. Fo r example, K e v i n said compromise in this respect was a " b i g t h i n g " because he was 152 RESULTS stil l t r y ing t o enjoy life. Furthermore, some informants recognized that this aspect o f compromis ing helped them maintain the changes over the long- term. 4.4.2.2. Cycles o f S l i p p i n g a n d G e t t i n g B a c k o n T r a c k Cycles o f sl ipping and gett ing back on t rack were c o m m o n dur ing the dietary change process as experienced by the informants o f this study. Cycles o f "s l ipp ing" o r " re lax ing" represented periods when they were not making or maintaining changes. Instead they fo rgo t t o w a t c h wha t they were eating, did not engage in new behaviours and/or re int roduced previous behaviours. B o t h slipping and relaxing involved "go ing back t o o ld ways . " Some informants indicated that sl ipping was a per iod when they d id not th ink about wha t they were eating. Some were conscious o f sl ipping, but "somehow not caring very m u c h , " wh i le others were less conscious o f sl ipping unt i l after i t had happened. Sometimes i t ' s funny though, I w i l l , w i thou t k n o w i n g it , I ' l l end up bingeing where I ' l l have a hot dog and maybe t w o or three days later I ' l l th ink "Geeze, y o u k n o w that was pret ty darn good I th ink I ' l l have another one o f those" or whatever the situation. A n d i t w o n ' t dawn on me unt i l later that " I d id have one o f those t w o days ago, I shouldn' t do that" but by then i t ' s t o o late. So sometimes I find that happens when I ' m not paying at tent ion and I ' l l start eating the so called bad stuf f more often. U n t i l I see mysel f and I go " O h - o h , gee I d id that again. I ' l l have to cut back on that ." ( laughing) A n d I ' l l be g o o d fo r a bit. I ' m very, I guess lazy. I let m y guard d o w n sometimes and i t jus t happens. Other t imes, when I ' m paying attention I guess, i t ' s i n the back o f m y mind and I ' m ... then I w o n ' t do it. B u t I guess sometimes, yeah I jus t let i t go. (Kev in ) Sti l l , other informants rejected the idea that slipping involved being less concerned: Anne said she had never experienced a per iod when she had not been concerned about maintaining healthy eating behaviours; and Janice thought i t was more that she was " w e a k or weak-w i l l e d , " but she was stil l concerned. Informants w h o relaxed believed i t was okay to reintroduce some previous eating behaviours or inappropriate foods because they had reached 153 RESULTS their goals o r were close to reaching them. However , of ten they later had t o remove these allowances and get back on t rack because their l ip id levels had gone up and/or they had regained some weight . There were many variations among the informants in terms o f h o w of ten they slipped, h o w m u c h they slipped, and h o w long the slip lasted. M a n y informants on ly slipped a small amount, once i n a wh i le and/or f o r a short per iod o f t ime before they were able t o "ge t back o n t rack . " B u t i f y o u ... f o u l u p o n one meal, you ' re only four hours away f r o m another meal and get t ing back on t rack again. So ... I mean I ' m not go ing to punish mysel f i f I cheat occasionally. (Janice) Y o u sti l l pound ou t every once and a whi le. Every once in a wh i le I ' l l have a 200 gram o f fat day. I just - 'Cause I don ' t really care. I mean I d o n ' t care about i t in the long run as long as I k n o w that ... I don ' t have t o hi t that 50 grams o f fat everyday k ind o f th ing and I ' m not really wo r r i ed about i t , as long as I k n o w that I ' m sort o f generally i n that bal l park al l the t ime. Y o u go over i t once in a whi le, you b l o w the thing, wel l . . . (gestures that i t doesn' t matter) . (Bruce) Other informants, such as Kev in , slipped much more of ten and t o a greater extent. There were also instances where some informants slipped so much that they gave up mak ing changes and went back to their previous eating behaviours. For example, D o u g repor ted mak ing changes but " n o t st icking to the p rogram" fo r more than three to six months. Several factors wh ich promoted slipping were identif ied. M a n y informants, such as Grace and Claudia, experienced more "s l ipping per iods" when they ate away from home (e.g. at others ' homes, in restaurants, when traveling). Sometimes this occurred because the temptat ions were greater o r the event was deemed " a special occasion." Other t imes i t occurred because they were less in contro l o f the availabil i ty o f foods and h o w they were prepared. Claudia reported that slipping did not occur because she wanted or craved foods 154 RESULTS (she found that she d id not want foods she knew were not good fo r her), instead her l i festyle inf luenced sl ipping in that her friends loved to eat. Other informants had a harder t ime identi fying w h y sl ipping occurred. M a t t suggested several factors wh ich may have caused it, such the patterns at home changing (because his w i fe had returned to school) and being under a fair amount o f stress. W h e n he was stressed, he found i t more di f f icul t to be concerned about his l ip id levels and maintain a mot iva t ion to do something about i t because he had other priorit ies at the t ime. Several other informants also noted that stress promoted slipping because i t caused them t o eat a greater vo lume o f f o o d and/or more eat inappropriate foods. (Stress) could sort o f precipitate ... sort of, what I w o u l d call sort o f a b i t o f a regression to some o f this other ... we l l eating too much or dr ink ing t o o much, whatever. This sort o f thing. (Ol iver) Interest ingly, M a t t also thought the slip in his eating behaviours may have been inf luenced by the fact that he had not exercised as much recently. H e speculated that "cu t t i ng back on the exercise brings back the o ld sedentary lifestyle and habits." Ol iver, Janice and D o u g also connected their eating behaviours w i t h their exercise patterns. Janice believed she could not isolate exercise from eating and that she could not be successful unless exercise was equal to , o r more impor tant than, the diet. Essentially, they found i t easier to maintain healthy eating behaviours w h e n they engaged in regular exercise. Then i f the exercise sl ipped, the eating behaviours slipped as wel l . 'Cause I always figure i f I ' m go ing to put the w o r k into i t . . . then I guess i t ' s , m y mind is saying to me " O k a y you just went out and ran 5 miles so n o w you ' re go ing t o come home and eat that stuff?" So i t ' s ... I guess i t ' s that i f ... yo i i ' r e mind is saying you ' re go ing out for a run, your mind is cont ro l l ing i t n o w 'cause i t ... I don ' t l ike running, but I k n o w it works , so i f i t ' s d r iv ing me t o run, then i t ' s go ing to drive me to not eat them things. ( D o u g ) 155 RESULTS F o r some informants slipping occurred because they d id not receive enough feedback or support t o maintain their mot ivat ion. Others slipped because they enjoyed inappropriate foods or eating behaviours too much and disl iked appropriate foods or behaviours o r because they d id not obtain desirable outcomes and perceived dietary modif icat ions w o u l d not help them achieve such outcomes. Other factors wh ich promoted sl ipping were unexpected events (such as changes to routines) and the emergence o f other pr ior i t ies (such as stress). Wh i le some informants t r ied to avoid situations that posed a high r isk fo r sl ipping, they were all f lexible about t ry ing to stay on the d i e t — n o t denying themselves by a l lowing treats was a coping strategy used by almost all o f informants to make the change process more enjoyable. Get t ing back on t rack represented the transit ion from sl ipping t o again mak ing or maintaining changes in order to achieve desirable results. Since Grace and Claudia experienced sl ipping when they were away from home, they were easily able t o get back on t rack w h e n they returned home. For example, Claudia simply adjusted fo r i t the next day. Janice was also able to get herself back on t rack fair ly easily. She asked hersel f " W h a t w i l l happen i f I slip and I don ' t go back?" and reminded herself o f the posit ive outcomes she had achieved (she loved clothes and had spent a lot o f money on nice clothes so she wanted t o be able to wear them, and she loved feeling " w e l l " and the " l ight feel ing" she had n o w ) . Fo r Janice, achieving these posit ive outcomes was "mot i va t ing" and she believed that i f someone did not see improvements he/she w o u l d end up slipping. A f te r sl ipping, D o u g found i t hard to target his eating behaviours directly; instead, he found i t easier t o start running again (wh ich he d id not enjoy do ing either) and have the fact that he was exercising help h i m get his eating behaviours back o n track. Similarly, Ol iver thought i t was easier to target exercise first and 156 RESULTS have that influence his eating behaviours. I th ink wha t ' s increased more is the consciousness that I H A V E T O maintain the physical activity. This is l ike number one fo r me. A n d then I th ink everything else seems to be relative to that. Because i t cuts, w h e n I exercise more I have, i t cuts back o n m y appetite and I ' m more conscious I t h ink o f what I ' m doing ... what I ' m eating ... also you ' re not as l ikely t o ... d r ink whi le you ' re eating or whatever. So i t ... t o me I th ink that 's probably the most important single factor. (Ol iver) Others found i t more di f f icul t t o get back on track and i t t o o k longer fo r t hem to become aware o f the negative consequences o f slipping. Usual ly another visi t t o the L i p i d Cl in ic to have their b lood l ip id levels measured helped them get back o n track. W e l l I guess from my sort o f analytical perspective i t gives me some sort o f numerical results wh ich are tel l ing me that what I have been doing in the past is w o r k i n g and so that k ind o f gives me a feeling o f " O k a y ... i f I ' m backsl id ing n o w then this is just go ing to reverse all the effort I ' ve put i n over the last 8 months real ly." Right. So i t gave me a l i t t le bi t o f an incentive ... seeing, as I say, seeing numerical results. Bu t , again I 've seen m y weight t u r n around too . So i t ' s k ind of, i t ' s an adjunct in terms o f an incentive. I t ' s not, i t ' s not a sole incentive by i tsel f by any stretch.. . Seeing h o w easy the tu rn around ( in m y we igh t ) was really is sort o f . . . gives you a bi t o f a k i ck in the but t t o ... really seriously get back into the exercise plan and so on in part icular and ... get B A C K to paying attent ion to the meals somewhat more and so on. ( M a t t ) I n a sense, the L i p i d Clinic served as a "real i ty check" or a reminder that the informants had an ongo ing condi t ion w h i c h required maintaining the changes over the long- term. Consequently, i t helped re-mot ivate them to get back on track. Unfor tunate ly fo r some informants these visi ts were t o o far apart t o keep them on t rack between each visit. 4.4.2.3. E v a l u a t i n g Ou tcomes a n d E f f o r t s a n d M a k i n g Decis ions A s described earlier, informants ' mot ivat ion to init iate or maintain the change process was inf luenced by the feedback they obtained. Essentially, they either d id o r d id not achieve desirable outcomes. A f te r receiving feedback, informants then weighed or assessed the 157 RESULTS desirable o r undesirable outcomes in relat ion to the effort they had expended t o make changes or maintain healthy eating behaviours, and they made a decision about h o w t o proceed. The decisions that resulted from this evaluation process were to a) t ry harder o r cont inue making changes, b ) maintain the changes wh ich were made, c) relax (i.e., re introduce some previous eating behaviours), and d) give up (i.e., return to previous eating behaviours). Therefore, after evaluating efforts and outcomes, informants either cont inued mak ing more changes or stopped mak ing changes and ended the process. For some informants the process o f making changes was circular, i n that they completed one or more cycles o f making changes and then decided to maintain the changes they had made w i thou t making new ones. These individuals were no longer actively engaged in mak ing new changes. A t times, they al lowed themselves to relax or re introduce some previous eating behaviours, consequently, they lost some o f the desirable outcomes they had achieved earlier and had to repeat one or more loops o f the model to regain those desirable outcomes. Consequently, fo r these individuals, the process o f mak ing changes involved intermit tent cycles o f mak ing and then maintaining changes. Fo r others the process was spiral because cycles o f mak ing changes was an ongoing process. These informants completed a cycle o f the model , evaluated their efforts and outcomes, then decided to make more changes whi le maintaining the changes they had already made as they w o r k e d towards the " ideal diet" or the diet promoted at the L i p i d Clinic. F o r a few informants the process was a repetit ive circle o r semi-circle because they made changes, but d id not maintain them or d id not maintain enough o f the changes to make a difference. They usually gave up or stopped making changes w i thou t adopt ing any new 158 RESULTS behaviours and d id not become mot ivated to start making changes again unt i l they visi ted the L i p i d Clinic. However , even then they simply repeated the cycle by making the same changes they t r ied to make before. ( M y eating) changes and then I seem to k ind o f dr i f t back in to the same ... traps as what I was in before. ... A n d I always come out o f ( ta lk ing t o the dieti t ians) th ink ing okay and fo r a l i t t le whi le i t seems t o w o r k . A n d then i t seems I always dr i f t back after ... t o it. (Doug) The final outcomes o f informants ' dietary change process were g iv ing up (i.e., re turn ing to o ld eating behaviours) or maintaining the changes (i.e., adopt ing new eating behaviours). Overal l , informants made changes to one or more eating behaviours by undergoing cycles o f mak ing changes. These cycles involved compromis ing to find a personally acceptable balance between h o w they defined enjoying l i fe and the need fo r t hem t o make enough changes to achieve desirable outcomes. Where informants found a balance between enjoying l i fe and making enough changes influenced the process o f mak ing changes in terms o f wha t and/or h o w many changes were made. Cycles o f mak ing changes also invo lved cycles o f sl ipping and gett ing back on track, as we l l as evaluating outcomes and efforts and making decisions about where to proceed next. 4.4.3. Intervening Factors Several intervening factors seemed to influence the process o f dietary change at any stage and either made i t easier and helped the informants make or maintain changes, o r made i t harder and were barriers to the change process. Intervening factors inf luenced a) whether o r not informants init iated the process in the first place (these factors were discussed previously as driving factors); b) whether or not they found a balance that enabled them to make changes or engage in many behaviours at the healthier end o f the scale; c) whether or 159 RESULTS not they slipped and/or were able to get back on track, as we l l as d) whether o r not they decided to cont inue making changes, to maintain the changes, or t o give up. Table 4.5 lists the intervening factors that made i t easier fo r informants to make or maintain changes. Table 4.6 lists the intervening factors that made i t harder fo r informants t o make or maintain changes. The repet i t ion o f some factors in bo th tables indicates that several factors wh ich made it easier fo r some informants were the same ones wh ich made it harder fo r other informants. F o r example, starting closer to the unhealthy end o f the scale made i t easier fo r some informants t o make changes, but made i t harder fo r others. Therefore, a l though i t w o u l d be nice to have a simple list o f factors that made i t easier o r harder, i t is impor tant to recognize that factors influence different people in different ways. Wh i le most o f the intervening factors identif ied in the tables have already been discussed, get t ing feedback and abil i ty to devise coping strategies have not yet been explained. Before expanding o n these factors, several environmental barriers should also be noted. The main environmental barriers to making and maintaining changes w h i c h were identi f ied included: a) a lack o f personal contro l over food availabil i ty, b) f o o d preferences o f fami ly members and friends and c) being around unsupport ive individuals. Since many environmental barriers were associated w i t h the amount o f cont ro l individuals have over f o o d availabil i ty, being away from home was an important situational barrier fo r most informants. F o r some, another environmental barrier was their percept ion that they received poor treatment at the L i p i d Clinic. M a t t had doubted he w o u l d go back after his first visi t because o f the lack o f concern on the part o f the staff about the amount o f t ime people had to wa i t fo r a scheduled appointment: I t ' s a disincentive to w o r k w i t h these people- ... The people here treat y o u 160 RESULTS Table 4.5 Intervening Factors Which Act As Helpers H E L P E R S • Characteristics o f the condit ion: • K n o w i n g and understanding. . . -mak ing one's o w n decisions -what changes are required about what is "reasonable" -making the r ight changes - h o w many changes are required • Degree o f ongoing mot ivat ion: -making enough changes -concerned about the diagnosis -perceived consequences • A m o u n t o f change required: taken seriously -start ing point closer t o unhealthy -personal meaning fo r making end o f the scale changes is established -easy t o target wha t behaviours -perceived abil i ty t o make changes require modi f ica t ion -a posi t ive att i tude is established -start ing point closer t o healthy -past outcomes. . . end o f the scale - leading to t ry ing harder or -changes are more acceptable maintaining changes because o f previous f o o d -resolving to make changes preferences • Get t ing sufficient feedback • N o t sl ipping t o o much/ too of ten and/or - to evaluate outcomes and efforts, able t o get back/stay o n t rack make decisions, and sustain -cont inue t o " w a t c h " mot iva t ion -having sel f-control -maintaining other behaviours • Personal circumstances: -exercising -support ive l iv ing situation -reconcilable gendered social role • Soeiocultural environment: -at the " r i g h t " life-stage - food preferences o f others are support ive • Ab le t o devise coping strategies -appropriate foods available 161 RESULTS Table 4.6 Intervening Factors Wh ich Act As Barr iers BARRIERS • Characteristics o f the condit ion: • N o t knowing/understanding. . . -abstract condi t ion -what changes were required -no symptoms -not mak ing the r ight changes -no immediately tangible - h o w many changes were required feedback -not mak ing enough changes -variable and uncertain outcomes -may lead to g iv ing up • A m o u n t o f change required: -start ing point closer to unhealthy • Degree o f ongoing mot ivat ion: end o f the scale -not concerned about the diagnosis -changes are unacceptable -perceived consequences not because o f previous f o o d taken seriously preferences -posit ive att i tude not established -start ing point closer t o healthy -perceived inabil i ty to make end o f the scale changes -hard to target wha t more can -no personal meaning fo r making be modi f ied changes is established -not resolving to make changes 0 Eat ing too much f o o d -past outcomes. . . -eating to relieve boredom -lead t o g iv ing up or relaxing -not want ing to waste f o o d • N o t get t ing sufficient feedback • Slipping too much/ too of ten and not -feedback not frequent enough gett ing back on t rack -unable to sustain mot ivat ion - forget t ing t o " w a t c h " -not having enough sel f -control • Personal circumstances: -not maintaining other behaviours -upbr inging -not exercising -unsupport ive l iv ing situation - interposing gendered social role • Soeiocultural environment: -at the " w r o n g " life-stage - food preferences o f others are -changes in routines, stress, unsupport ive special occasions - inappropriate foods available • N o t able t o devise coping strategies • Financial cost o f healthy eating in restaurants 162 RESULTS l ike you ' re not important. W e l l fine, I don ' t have to be here. I can be somewhere else. ( M a t t ) 4.4.3.1. Gett ing Feedback Get t ing feedback was an important intervening factor in helping informants become mot iva ted t o make and maintain changes, and enabling them to evaluate outcomes and efforts. In formants wanted to k n o w whether what they were doing was making a difference because i f the changes were not helping them achieve desirable outcomes many did not see the point o f cont inuing w i t h them. Several informants stated i t was di f f icul t t o be mot ivated w i thou t feedback. F ind ing out h o w they were doing gave them a goal to w o r k towards. F o r example: I f y o u k n o w that you ' re having ... a test at the end o f the mon th in school y o u study fo r it. I f you k n o w that you ' re having a b lood test ... that 's a goal o r i f I ' m go ing to we igh mysel f at the end o f the week I have a goal ... we l l then y o u ' v e go t something to w o r k towards, right. A n d y o u k n o w that the test is coming up and so i t keeps i t more in the forefront o f your mind, o f wha t y o u ' r e actually aiming for. ( M a t t ) Wh i le some informants used shifts in their weight, physical condi t ioning, appearance or general health as feedback to determine whether the changes they were mak ing were w o r k i n g , having their b lood l ip id levels measured was a very important source o f feedback fo r most informants (especially i f they had no other source o f f e e d b a c k — f o r example, by already being at a fair ly opt imal weight ) . Ol iver said it w o u l d "g ive val id i ty to whatever changes have happened" and thought " i t w o u l d be a very important check." Janice said i t was very mot iva t ing to k n o w what she was doing was making a difference. Consequently, w h e n the doc tor at the L i p i d Clinic said he wanted to see her again in a year, she asked h i m t o see her in six months. She thought " i f I knew that, I w o u l d be a l i t t le more strict w i t h myself ." 163 RESULTS Other informants also indicated that i t was hard to stay mot ivated w h e n there was no discernible feedback or the feedback was too infrequent to keep them on t rack between visits. F o r D o u g , the feedback o r reinforcement f r o m the L i p i d Cl in ic was not f requent enough t o help h i m maintain the changes over t ime. A f te r a few months he always sl ipped back t o his previous eating behaviours. Then when he returned to the L i p i d Cl in ic he w o u l d be back where he started and w o u l d repeat the cycle by making the same changes again. The th ing is I don ' t always th ink about what I ' m eating. I t seems i t ' s only 3 months after that, then i t . . . I th ink i t w o u l d be better i f . . . L i k e they say " O k a y come back and see me in 6 months." I th ink that 's t o o long. I th ink i f y o u came back even M O N T H L Y it w o u l d be better fo r me because then y o u k n o w " O k a y I 've got to go back there in a m o n t h " so then I 've go t ta k ind o f be good. ( D o u g ) M a t t also recognized that feedback needs to be frequent enough in order fo r i t t o be useful: Y o u need feedback mechanisms and ... the feedback has to be t imely. I mean i f there's b ig lags in the feedback, it doesn't do any good. I t doesn' t accomplish anything or y o u start gett ing this (gesturing up and d o w n ) k i n d o f th ing go ing when the feedback is too slow. ( M a t t ) H e believed having l ip id levels assessed every six months or yearly was not helpful because i t d id not "suppor t the intensity needed" to make and maintain changes. Fur thermore, w h e n l ipids were measured, " the results were less signif icant" because o f the frequency they were done. Wh i le he d id no t k n o w h o w expensive l ip id tests were nor h o w frequent ly they cou ld be done and sti l l be meaningful, he thought "having some sort o f feedback o n a month ly basis w o u l d be more effect ive." I f i t was any longer, he d id not th ink i t was useful as a feedback mechanism or a mot ivator because "people don ' t w o r k o n a yearly basis." 4.4.3.2. Ab i l i t y to Devise Coping Strategies Another intervening factor was informants ' abil i ty to devise coping strategies. These 164 RESULTS strategies helped informants make changes and maintain healthy eating by either increasing the enjoyment o f mak ing enough changes, minimiz ing the impact o f factors that made i t harder, or maximiz ing the impact o f factors that made it easier. Fo r example, a l though B ruce was not act ively making change at the t ime o f the second interview, he was sti l l l ook ing fo r ways to help h i m maintain the changes he had made. W e l l I ' m look ing fo r l i t t le strategies all the t ime and i f i t ' s in your mind , y o u hear things or you ' re look ing in books and that. I don ' t go ou t and buy a thousand books on health, but occasionally there ' l l be things around. (Bruce) Table 4.7 lists the strategies some informants used to make establishing healthy eating behaviours easier and more enjoyable. Again, whi le most o f these strategies have already been discussed, a f e w have not yet been explained. These include keeping the diet interesting, cont ro l l ing f o o d availabil ity to avoid temptations, not denying self by a l lowing treats occasionally, not making exceptions or slipping fo r t oo long, and incorporat ing new behaviours into a lifestyle. Table 4.7 Devised Coping Strategies Keeping the diet interesting Enl ist ing the support o f others Eat ing different foods instead o f "d ie t ing" M a k i n g l i t t le changes over a longer per iod o f t ime Contro l l ing food availability to avoid temptat ions Avo id ing foods or situations that were tempt ing N o t denying self by a l lowing treats occasionally N o t making exceptions or sl ipping fo r t oo long Incorporat ing new behaviours into a l ifestyle 165 RESULTS Keeping The Diet Interesting In formants reported using strategies to keep their diet interesting and make meals appealing so they d id not get bored w i t h the same o ld foods. Several informants t r ied dif ferent recipes t o keep the diet interesting. Other common strategies were eating a var iety o f foods and t ry ing ethnic foods. Claudia also kept her diet interesting by t ry ing unusual vegetables (e.g., having artichokes sometimes instead o f broccol i ) , adding dif ferent spices to foods such as chicken (so they had different flavours and were not the same all the t ime) , having a glass o f red wine occasionally w i t h supper t o make the meal special, and choosing foods w i t h strong flavours (e.g., sprinkl ing small amounts o f o ld cheddar over some foods to add taste). M a t t referred to choosing foods w i t h strong flavours as having foods w i t h h igh taste value. A n d I found that by aiming fo r foods that were really h igh in taste value I cou ld eliminate the h igh taste level that fat brings to foods. So I ' d order l ike Cajun chicken o r something l ike that, right? So i t ' s got spicy s tu f f and so o n and that sort o f brought up the taste level so I d idn ' t feel l ike I was missing the taste o f the fat i n the food. ... So that was k ind o f m y strategy ... was to make sure I had really tasty things, l ike crispy dried bacon o r something, w h i c h is really tasty, but there's darn l i t t le fat left in it, s tu f f l ike that. So I was stil l get t ing a g o o d taste hi t from the food and enjoying the taste o f the food , but not sucking up 40 grams o f fat w i t h every meal. ( M a t t ) Controlling Food Availability A s indicated earlier, i t was easier fo r informants to engage in healthy eating behaviours at home because they were better able to contro l the f o o d available to them. B y cont ro l l ing f o o d availabil i ty, informants lessened the choices available to them, reduced the amount o f th ink ing involved i n deciding what t o eat or not eat, and eliminated the temptat ion to eat inappropriate foods. A lso , foods w o u l d not be there i f they had cravings fo r them. 166 RESULTS In formants indicated the importance o f this strategy when they ta lked about the dif f icult ies w h i c h arose when inappropriate foods were available at home or w h e n they ate away from home. Whi le Bruce said not buying inappropriate foods was " just c o m m o n sense" because he did not want those foods, when they were available at home it was di f f icul t not to eat them because then they were there and he wanted them. Janice also found i t d i f f icul t t o maintain healthy eating behaviours after she entertained because inappropriate foods were lef tover in the fridge. W h e n Claudia traveled she had to consciously make decisions about what t o eat on an event-by-event basis because there was more f o o d available and the temptat ions were greater. A s indicated earlier, some informants contro l led f o o d availabil i ty away from home by carefully selecting the type o f restaurant they went to . Others brought their o w n f o o d from home. Fo r example, Richard started br inging fruit, vegetables, and salads to w o r k , instead o f grabbing a muf f in on the w a y in the morn ing and then rushing out fo r some fast f o o d at lunch. Overal l , instead o f having to exercise sel f-control o r be reminded that they had to modi fy their eating behaviours, informants found i t easier t o simply cont ro l the f o o d available at home. N o t D e n y i n g Sel f N o t denying oneself all the t ime by a l lowing treats was another coping strategy used by all o f the informants to help them make or maintain changes. A l l o w i n g treats made i t easier to compromise and find a balance because i t increased enjoyment wh i le sti l l permi t t ing them to achieve desirable results. For example: I mean I don ' t th ink that y o u can discipline yoursel f endlessly. A n d I th ink i t ' s G O O D f o r y o u to fal l o f f the wagon and, i f you ' re enjoying i t o r i f i t ' s a t ime l ike that . . . A n d then when I ' m eating i t I ' l l of ten take the crusty shell o f f the fish and leave a th i rd o f i t or ha l f o f i t o r something l ike that behind and jus t have the fish. A n d I seldom eat all o f the fries, so i t ' s a l i t t le indulgence that I 167 RESULTS guess is probably H E L P I N G you stay on the diet the R E S T o f the t ime really. (Steve) B ruce said he never consciously thought " O h I can't have that" because as soon as he thought he could not have something, he immediately wanted it. Therefore, by k n o w i n g he was not denying himself, he was less inclined to want inappropriate foods. Similarly, Tracy d id not deny herself because she wanted to have foods in moderat ion and lead a balanced l i fe rather than be in a "d ie t f rame o f m i n d " and deprive herself. Impor tan t distinctions among informants were h o w of ten they a l lowed treats and the amount o f f o o d they al lowed. Informants w h o were determined t o maintain the new behaviours they had established had treats occasionally and of ten in smaller amounts. I guess y o u can' t deny yoursel f forever certain foods. I th ink m y att i tude n o w is ... have a t iny l i t t le bit, but i f you ' re going to have a l i t t le piece o f dessert cut i t smaller so that you ' ve had it and you don ' t feel l ike you ' re being punished, but you ' re having something. (Janice) Hav ing sel f-control t o l imi t por t ion size and/or frequency o f the event was an impor tant aspect o f no t denying oneself. Janice al lowed treats because she could cont ro l it. In formants w h o were determined to maintain new behaviours indicated i t was easier to not deny themselves w h e n they were away f r o m home or on special occasions so they w o u l d not be tempted t o treat themselves t o o of ten at home. That is, as discussed below, they d id not wan t t o make exceptions at home. Fo r them, having occasional treats was not v iewed as "s l ipp ing , " but as a strategy to keep themselves on the diet the rest o f the t ime. I n contrast, informants w h o were in the early stages o f making changes reported " t reat ing themselves" fair ly regular ly so they d id no t miss foods nor feel l ike they were being deprived. That is, they were mak ing l i t t le changes towards healthier eating, but often slipped back into o ld behaviours. Consequently, " t reat ing themselves" was not a strategy to keep themselves on the diet the rest o f the t ime, 168 RESULTS but represented periods o f sl ipping in wh ich they d id not " w a t c h " o r pay at tent ion to what they were eating. N o t M a k i n g Excep t ions Some informants indicated that prolonged slipping resulted from th ink ing " O h we l l , jus t this once . . . " because one exception ended up being one more except ion and then one more and so on, and then once they had slipped that much i t was hard to get back on track. Fo r example: I f y o u go over to someone's house and they go t a smorgasbord and y o u figure "Okay , I shouldn' t be eating this, but hey fo r one night what the heck." So by the end the night you 've eaten everything around, y o u ' v e destroyed i t all, but then y o u th ink " O k a y the next day I ' m going to start over again from that morn ing . " B u t sometimes i t doesn't happen ... you get up in the morn ing and say " O h we l l , I may as we l l have my eggs too , because I ' m o f f i t and then I ' l l start in the af ternoon." A n d then i t ' s l ike 3 days later y o u ' r e . . . " O h we l l , forget about i t . " ( D o u g ) T o avoid this k ind o f situation, some informants believed i t was easier to stay o n t rack by not mak ing exceptions and slipping in the first place. I t does make i t very dif f icult when everybody's cook ing steak or y o u put a roast o n and that 's what the major i ty o f people are eating ... and y o u can ' t or y o u don ' t L I K E to. I guess i t ' s always easy to make one except ion, but as soon as y o u start doing that then there's another exception, another except ion, and y o u ' v e lost it. So I t ry not to do that. ( I n those situations) I had the vegetables and baked potato ... and then I ' d go home and c o o k some fish and chicken. (Richard) Richard believed making exceptions at regular fami ly barbecues w o u l d cause h i m to lose his " m o m e n t u m . " Janice and Claudia thought i t was important to not make exceptions w h e n they were at home. They knew i f they made an exception, they w o u l d want to have the f o o d again and w o u l d be more l ikely to give in to their cravings. Therefore, the main dist inct ion between not mak ing exceptions and not denying themselves was the situation in w h i c h informants used 169 RESULTS the dif ferent strategies. M a n y informants were reluctant to make exceptions in everyday situations because they d id not want to associate inappropriate foods w i t h regular events. Thus, having treats was reserved fo r special occasions or when they were away f r o m home so they were not always denying themselves, but at the same t ime were min imiz ing the temptat ions w i th in everyday situations. I n c o r p o r a t i n g N e w B e h a v i o u r s Incorpora t ing new behaviours refers to the tendency fo r changes to become part o f in formants ' everyday l i fe, thus making i t easier fo r them to maintain the new behaviours. Un l i ke the early stages o f making changes wh ich were characterized by having to " w a t c h " or " t h i n k " about everything that was consumed, incorporated behaviours were sometimes per formed unconsciously. Whi le M a t t said he stil l had to consciously make choices about what t o eat and not eat, i t was "becoming more o f l ifestyle choice" in that there was less o f a desire fo r inappropriate foods as t ime went by. I really not iced n o w i f I have something l ike say fish and chips, h o w greasy the f o o d feels now. I really, really notice the saturated fats, that k ind o f th ick greasiness. A n d I don ' t enjoy them nearly as much ... the k ind o f greasy taste that 's left i n your mouth, and on your face and i t ' s disgusting. ( M a t t ) M a n y informants indicated that the foods they used to eat did not appeal t o them n o w or that they " g o t used to i t . " B y establishing new food preferences, new eating habits, and/or new routines, new eating behaviours became a part o f some informants ' l i festyle o r " w a y o f l i v ing . " Those w h o did not incorporate new behaviours had to w o r k consciously o r " w i t h determinat ion all the t ime" at making changes or maintaining new behaviours, even after engaging in the change process fo r many years. Consequently, i t was harder to maintain new behaviours because they always had to th ink about what they were do ing or eating. 170 RESULTS Overal l , the intervening factors identif ied above i l lustrate the complex i ty o f the dietary change process. The various factors influenced the process by either mak ing i t easier or harder fo r informants to make and maintain changes. A t t imes, the same factors affected dif ferent in formants i n different ways. Get t ing feedback and abil i ty t o devise cop ing strategies were ident i f ied as important intervening factors wh ich had not been previously defined. 4.4.4. S u m m a r y This chapter examined informants' experiences w i t h the process o f l ip id - lower ing dietary change. The hyperl ipidemic condi t ion o f being at r isk fo r C H D was v iewed as an abstract concept that required changes to mult iple behaviours w i t h uncertain and variable outcomes among individuals and required ongoing decisions about what t o do in var ious situations. F o r them, healthy eating involved "watch ing , " "being careful , " and " t h i n k i n g " about f o o d appropriateness. Establishing healthy eating behaviours involved eating less o f some foods, eating more o f others, substituting foods and altering the method o f preparat ion. Ea t ing away f r o m home also involved order ing carefully, eating selectively, mak ing the best o f it, and l imi t ing the frequency o f the event. The factors const i tut ing and influencing their dietary change efforts were organized in to a conceptual model wh ich centred around the process o f finding a balance. Several intervening factors were singled out as driving factors wh i ch helped informants init iate and maintain the change process. Once init iated, cycles o f mak ing changes invo lved compromis ing t o find a balance between enjoying l i fe and making enough changes. A f te r evaluating outcomes and efforts, informants made decisions about the value o f mak ing changes in l ight o f the outcomes achieved and efforts required, what changes to make (or not 171 RESULTS make), the value or meaning given to enjoying l ife, as we l l as the impl icat ions o f changes to personal circumstances (e.g., changes in life-stage). Such decisions resulted in informants cont inuing the process to make more changes or ending the process by g iv ing up ( return ing to o ld eating behaviours) or by maintaining the changes (adopt ing new eating behaviours). The conceptual model also incorporated cycles o f sl ipping and get t ing back o n t rack w h i c h were experienced by many informants. Var ious other intervening factors that inf luenced the change process were also identi f ied. 172 D I S C U S S I O N CHAPTER 5: DISCUSSION The purpose o f this study was to increase our understanding o f the process o f l ip id -lower ing dietary change as experienced by hyperl ipidemic adults w h o were actively t ry ing to reduce their b lood l ip id levels th rough dietary change. This chapter discusses the major findings in relat ion to the existing l i terature and emphasizes what this study adds to our understanding o f the process o f dietary change. L imi tat ions o f the study and its impl icat ions fo r research and practice are also presented. 5.1. Healthy Eating The informants ' understandings o f healthy eating and f o o d appropriateness were congruent w i t h current scientific guidelines as described in the l i terature review, but tended t o be somewhat simplif ied. I n keeping w i t h the widespread emphasis o n dietary fat, all in formants were concerned about the amount o f fat in their diets. Wh i le some had quanti tat ive guidelines fo r l imi t ing their fat (e.g., 50 grams o f fat a day), there was l i t t le evidence that they calculated their actual intakes on a daily basis. Instead, they seemed t o jus t l imi t h o w much and h o w of ten they ate high-fat foods. In formants ' tendency t o focus o n their general fat intake was congruent w i t h current populat ion guidelines w h i c h emphasize no more than 3 0 % o f calories from fat (NCEP, 1994). Their tendency to evaluate foods w i t h i n the context o f their overal l diet was also congruent w i t h current guidelines w h i c h recognize that adherence t o a step-1 diet reflects average habitual nutr ient intake (Kr is -E ther ton et al., 1995). 173 D I S C U S S I O N The importance o f the different types o f fats and other f o o d components was less we l l understood by informants. Some informants targeted saturated fat as we l l as to ta l fat, and some k n e w that certain vegetable oils, such as canola and ol ive oils (bo th h igh in monounsaturated fats) were better fo r them than palm and coconut oils (h igh in saturated fats). There was also evidence o f incomplete understandings o f the relative importance o f reducing fat and saturated fat t o lower b lood l ip id levels versus the importance o f reducing dietary cholesterol. However , unl ike a recent Canadian populat ion survey w h i c h found that 6 9 % o f respondents completely or somewhat agreed, mistakenly, that " the amount o f cholesterol people eat is the major factor that affects their b lood cholesterol" (Reid et al., 1996), most o f the informants in this study believed that fat was the bigger culpr i t . Finally, very f e w informants ta lked about eating more o f other dietary components (such as complex carbohydrates and f ibre) because o f their l ip id- lower ing effect. M o r e of ten, they ate more o f these foods in order to replace the calories they were losing by reducing the amount o f fat they ate. Those that were aware that these components may play a role i n lower ing their b lood l ip id levels were not target ing them at the t ime, but said they could target them i f they had t o make more changes to achieve more desirable outcomes. M o s t informants ' apparent single-minded focus on fat may be related t o the counseling practices at the L i p i d Clinic, however, i t is more l ikely related to their approach o f "mak ing l i t t le changes" in order to make the process more "doable. " In formants decided what behaviours, f o o d components and/or foods they were go ing to mod i fy and then jus t focused on those items whi le dismissing or ignor ing the others. Therefore, w h e n eating behaviours were considered separately, i t was apparent that informants were at mul t ip le Stages o f Change 174 D I S C U S S I O N at the same t ime. Fo r example, some informants were in the act ion stage fo r reducing their intake o f dietary fat o r jus t certain high-fat foods, however, w i t h respect t o other f o o d components o r foods they were stil l in earlier stages, such as precontemplat ion, contemplat ion or preparat ion. This observation supports the l i terature wh ich identif ies that i t is possible fo r people w h o are undertaking dietary change to be in more than one stage (Glanz et al, 1994). The strategies informants used to establish healthy eating behaviours are similar to those p romoted in the l i terature. The N C E P report (1994) recommends eating less o f certain foods (i.e., those high in fat, cholesterol, sodium), eating more o f others (e.g., breads and cereals, vegetables, f rui ts) , using lower- fat cook ing methods, and substi tut ing low-saturated fat foods (e.g., 1 % or sk im mi lk , margarine) when possible. Establ ishing healthy eating behaviours by eating less and eating more is also congruent w i t h Janas's (1993) findings that individuals operationalized their diets as a set o f dietary restr ict ions and allowances w i t h respect t o f o o d components, foods, and food groups. Fur thermore, their strategies are congruent w i t h the personal strategies developed by cardiac patients to maintain l o w fat diets, such as avoid ing foods, eating smaller amounts, eating treats, and l imi t ing intake before or after h igh fat consumpt ion (Wr ight , 1995). Finally, the specific strategies informants used to eat less fat are similar to those used by other Canadians, such as buy ing l ower fat products, using lean meats and t r imming the fat o f f meat (Reid et al, 1996) and fa i r ly congruent w i t h Keenan and colleagues' (1996) findings that the greatest decreases in dietary fat can be achieved by decreasing fat flavourings, recreational foods (e.g., snack foods, desserts), and cook ing fat, replacing meat, changing breakfast, and using fat -modi f ied foods. Strategies to cope w i t h f o o d availabil i ty i n other people's homes, such as eating selectively, mak ing the best 175 D I S C U S S I O N o f i t and l imi t ing the frequency o f the event are congruent w i t h those reported i n the l i terature (Wr igh t , 1995). A l t h o u g h the focus o f this study was dietary change, there was evidence that informants t o o k a mult i - factor ia l or lifestyle approach to risk reduct ion as recommended in the l i terature (MacDona ld et al, 1992; N C E P , 1994; Temple and Walker , 1994). I n addi t ion to mak ing changes toward healthier eating behaviours to lower elevated b lood l ip id levels, many informants were also target ing other health-related behaviours (such as exercise, smoking, and alcohol intake), and other risk factors (such as obesity and hypertension). However , as noted in the l i terature review, the mot ivators for these changes were not always health related as informants also wanted to improve their appearance, wear nice clothes, be able to do the activit ies they want to , and generally just feel better. 5.2. A Theoretical Framework of The Dietary Change Process Whi le I init ial ly believed one o f the main objectives o f this study was go ing to be to ident i fy the personal and environmental factors wh ich shaped the process o f dietary change as experienced by adults w i t h hyperl ipidemia, as data col lect ion and analysis proceeded i t became apparent that generating a theoretical f ramework o f the factors w h i c h const i tuted and inf luenced the process o f dietary change was more important in terms o f understanding h o w to best go about designing effective interventions that encourage individuals t o ini t iate a change in their behaviour, and maintain those new behaviours over the long- term. The theoretical f ramework developed to understand hyperl ipidemic adults ' experiences w i t h making dietary changes and the conceptual model constructed to i l lustrate the f ramework can be placed w i t h i n the existing l i terature pertaining to health behaviour change. Several 176 D I S C U S S I O N components o f the process o f dietary change f ramework and model not only support previous findings repor ted in the l i terature, but also add to them to fur ther our understanding o f the process o f dietary change. For example, Janas and colleagues (1993) explored hypercholesterolemic adults' experiences w i t h cholesterol- lowering dietary change, however their study focused on the cognit ive and behavioural aspects o f part ic ipants' dietary change experiences. I n l ight o f the findings presented here, i t is clear that the components identi f ied by Janas and others represent a distinct part o f the larger, ongoing process o f dietary change. Together, their model and the one presented here can in fo rm each other t o increase our understanding o f the process o f dietary change. The central dimension or perspective o f the process o f dietary change f r a m e w o r k (i.e., finding a balance between enjoying l i fe and making enough changes) is similar to Bruenjes's (1994) findings in her study o f the process used by middle-aged w o m e n t o achieve health. She found that "orchestrat ing health" (the te rm given to the process o f l iv ing health) invo lved balancing, pr ior i t iz ing, evaluating, moderat ing, and choosing in order t o orchestrate the physical, emot ional , and spiritual aspects o f their lives w i th in a context o f environmental and personal factors and relationships w i t h others. Whi le bo th processes involve balancing inner aspects o f one's self w i t h the environment, personal factors and relationships found in daily l i fe, there is a distinct difference between them. The process o f l iv ing health involved "orchest ra t ing" o r "conduc t ing" external factors or behavioural responses to these factors and the model depicts h o w the w o m e n responded to the events around them and accommodated personal factors (such as genetics, aging and disease) in order fo r them t o l ive health. I n contrast, the process o f making dietary changes involved active decision mak ing o n an 177 D I S C U S S I O N ongoing basis as informants t r ied to make behavioural changes so they could achieve desirable results. F ind ing a balance was a dynamic process in wh ich informants struggled w i t h making changes whi le also t ry ing to enjoy life. Compromis ing w i t h respect t o enjoyment o r making changes was necessary to achieve balance in certain situations. This substantive theory o f the process o f dietary change is similar t o Johnson's (1991) f indings that l ifestyle modi f icat ion involves a) serious consideration o f l i festyle changes (i.e., choosing a focus and determining what is reasonable), b) attempts t o implement and evaluate l ifestyle changes (i.e., evaluating outcomes and ef for t ) , and c) i f the outcomes are posit ive, the incorporat ion o f these changes into one's l i fe (i.e., maintaining new behaviours by incorporat ing them into a new lifestyle). Similarly, informants in her study also emphasized that changes should be gradual and not implemented quickly. Var ia t ion in h o w informants defined enjoying l i fe, made compromises, responded to intervening factors, and evaluated outcomes emphasizes the complexi ty o f the process o f dietary change. 5.2.1. Variable Responsiveness To Dietary Modifications Differences in the outcomes achieved by informants after mak ing changes supports the l i terature wh ich identifies that there are variations in the response o f b lood l ip id levels to dietary modif icat ions (McNamara and Howe l l , 1992; Bae et ah, 1993; Denke and Grundy, 1994; N C E P , 1994). Whi le the dietary starting point (i.e., the type o f diet they were consuming pr io r t o dietary modi f icat ion) may have played a role in the outcomes obtained by some informants, the interpretive nature o f the study made i t di f f icul t t o assess the role o f other factors identi f ied in the l i terature as contr ibutors to variable responsiveness (such as ini t ial l ip id status, the extent t o wh ich l ip id levels were elevated, and the differences in 178 D I S C U S S I O N inter indiv idual responsiveness to dietary modif icat ion). Nonetheless, the findings emphasize the importance o f recognizing that there is interindividual variabi l i ty w i t h respect t o h o w l ip id levels respond t o dietary changes, and as a result individuals w i l l always have uncertainties regarding the value o f lifestyle modif icat ions to lower b lood l ip id levels. 5.2.2. The Role of Concepts From Health Behaviour Theories M a n y o f the components o f the theoretical f ramework and conceptual model constructed i n this study have been previously ident i f ied in one or more o f the health behaviour theories described in the l i terature review. In formants ' mot iva t ion t o change their diets was affected by their perceived susceptibility t o heart disease and the severity o f the c o n d i t i o n — b o t h o f wh ich are components o f the Heal th Be l ie f M o d e l (Hochbaum, 1981 ; Rosenstock, 1990). Their degree o f mot ivat ion was also affected by their perceived abil i ty t o make changes and choose foods appropriately wh ich is congruent w i t h the self-efficacy concept included in several health behaviour theories (Strecher et al., 1986; Rosenstock et al., 1988). Final ly, informants ' mot ivat ion to change their diets was affected by their past experiences w i t h making changes and the benefits, barriers and outcomes they associated w i t h those efforts w h i c h are all aspects o f the outcome expectancy construct also included in many health behaviour theories. In formants ' perceptions about the ease and di f f icul ty o f per forming part icular behaviours were influenced by their level o f self-control t o wi thstand and/or avoid temptat ions, and the amount o f contro l they had over f o o d availabil i ty as predicted by the perceived behavioural cont ro l construct w i th in Ajzen's Theory o f Planned Behaviour (S imons -Mor ton et al., 1995). Their perceptions about the causal factor o f h igh l ip id levels 179 D I S C U S S I O N (i.e., genetics versus l ifestyle) influenced the extent to wh ich they embarked o n mak ing changes as indicated by aspects o f Weiner 's Locus o f Cont ro l framework (A l l i son, 1991). The findings also support the importance o f several characteristics included in Rogers 's D i f fus ion o f Innovat ions theory (Glanz, 1993). For example: informants looked fo r the relative advantage o f changes and made changes they thought w o u l d result i n benefits; the changes they decided t o make were compatible w i t h their desires to balance enjoying l i fe wh i le mak ing changes; the changes they made were flexible i n that they adapted them to var ious situations; many informants considered the cost-efficiency o f mak ing changes and avoided mak ing new changes i f i t became a case o f diminishing returns; and all informants were concerned about the observability o f the changes they were mak ing in that they sought feedback t o determine whether what they were doing was making a difference. In formants ' efforts t o make changes were also influenced by socio-environmental factors, such as f o o d availabil i ty and the influences o f family and friends, thereby, support ing the importance o f Social Cogni t ive Theory 's reciprocal determinism construct. I n terms o f the Stages o f Change framework, the findings con f i rm that dietary change is a process invo lv ing a continuous series o f changes. They also support the hypothesis that the act ion stage o f changing eating behaviours continues over months or years and involves many small steps o r processes along the way ( B o w e n et al., 1994). Fur thermore, the findings support the smoking cessation l i terature wh ich identifies that relapse makes subsequent attempts easier because individuals are more prepared and learn new strategies w i t h each attempt (Prochaska and DiClemente, 1983). A s many informants became experienced w i t h mak ing changes they slipped less frequently, found i t easier t o engage in the new behaviours 180 D I S C U S S I O N and found that th ink ing about making new changes was less daunt ing and required less contemplat ion pr io r to making changes. Therefore, being experienced w i t h mak ing changes also inf luenced their perceived abil ity (or self-efficacy) to make more changes. These observations are congruent w i t h B rowne l l and colleagues' v iews that relapse may have posit ive consequences i f past lapses or slips are used as learning experiences w h i c h prepare individuals fo r later success ( in Neumark-Sztainer and Story, 1996). The f indings also support concerns wh ich have recently emerged about the appl icabi l i ty o f the Stages o f Change f ramework to the process o f dietary change as a whole. Wh i le there is consensus that dietary change is composed o f many different behaviours and that individuals can be in more than one stage at any given t ime dur ing the change process depending o n the behaviour in question (e.g., fat vs. f ibre), there is less consensus that each behaviour should be examined individually. N i M h u r c h u and colleagues (1997) assert that assessing stage o f change fo r each food component that needs to be changed is a t ime-consuming and complex process wh ich "might not be helpful in terms o f captur ing all o f the components o f indiv idual behaviour" (p. 14). Furthermore, classifying individuals in to specific stages according to specific f o o d components or certain aspects o f their diets may not accurately assess their readiness fo r change or receptivi ty fo r learning and apply ing nut r i t ion in format ion. Wh i le explor ing whether stage o f change was consistent across general fat reduct ion versus six specific fat-reduct ion behaviours, Ffotz and colleagues (1995) found that "staging based o n general fat intake did not yield an accurate picture o f readiness t o reduce fat o r sufficient detail fo r tai lored intervent ion" (p. 116). Therefore, i f dietary change is considered as a whole , as was the case w i t h this study, questions arise as to h o w interventions 181 DISCUSSION should be matched or tai lored to an individual w h o is at mult ip le stages o f dietary change at any g iven t ime. Overal l , the f indings o f this study support the importance o f var ious concepts f r o m different health behaviour theories. The fact that concepts f r o m different theories played a role i n the process o f dietary change supports the v iew that no one theory adequately explains the complex process o f making dietary changes and indicates the importance o f using a mu l t i -theory approach w i t h respect to dietary behaviour (Glanz et al, 1990; H o t z et al, 1995). 5.2.3. D r i v i n g Fac to rs The dr iv ing factors wh ich influenced whether informants ini t iated and/or maintained the dietary change process are similar to those identif ied by Caggiula (1989) . Fo r an indiv idual to make changes, Caggiula reported that the fo l low ing condit ions must be present: a) being mot ivated; b ) perceiving that changes are in one's o w n self-interest; c) having the skills t o make the specified changes ; d) having bo th internal (cogni t ive) and external (social) forces that support change; and e) having posit ive support and reinforcement f r o m change agents, such as physicians or dietitians. For the informants o f this study, becoming mot ivated seemed to depend t o a great extent on whether informants were concerned about having h igh b lood l ip id levels wh ich supports Sporny and Contento 's (1995) finding that a state o f concern about avoid ing disease and achieving health remains important in the in i t ia t ion and maintenance o f behaviour change. Hav ing a family history also seemed t o increase in formants ' concern about having h igh b lood l ip id levels because they were more l ikely to perceive that having h igh b lood l ip id levels was serious and that they were susceptible to the consequences o f hyperl ipidemia. 182 D I S C U S S I O N I n addi t ion to being concerned, the theoretical f ramework ident i f ied that becoming mot ivated was greatly influenced by the extent to wh ich informants found personal meaning fo r mak ing changes, whi le actually ini t iat ing and maintaining changes was great ly inf luenced by the extent t o wh ich informants resolved to make changes. The f ind ing that personal meaning influences individuals' mot ivat ion fo r change supports Baker and Stern's (1993) observat ion that f inding meaning in chronic illness (or h o w individuals see themselves in relat ion to their illnesses) was the key process in self-readiness. Others have also ident i f ied that individuals were more l ikely to maintain new eating behaviours i f they had a st rong w ish t o change (McConaghy, 1989). However , an understanding o f w h y resolving t o change is an impor tant component o f the dietary change process has not previously been emphasized or described in the dietary change literature. T o understand w h y resolving t o change helped informants make and maintain changes i t is necessary to consider the dif ferent types o f mot iva t ion identi f ied in the l i terature review. I n general, the difference between the concepts o f " f ind ing personal meaning" and " resolv ing t o change" and Bote lho and Skinner's (1995) concept o f " in tegrated mot i va t ion " seem to be one o f semantics. Variat ions among informants w i t h regard to the extent that they found personal meaning and resolved to make changes, made and/or maintained changes, and needed feedback to sustain their mot ivat ion for change are related to Bo te lho and Skinner 's ideas about individuals ' dispositions toward change. Finding personal meaning and resolving t o change is congruent w i t h an "autonomous- integrated" disposit ion t o w a r d change in that these informants made changes because they really wanted to . N o t finding personal meaning or resolving to change, on the other hand, is congruent w i t h "autonomous- in t ro jec ted" o r 183 DISCUSSION "controlled" dispositions toward change in that these informants made changes because they thought they ought/should/must change or because others wanted them to not because they wanted to. These differences in dispositions may explain why some informants had a harder time maintaining their motivation to change and perceived that they needed more frequent feedback and reinforcement from health professionals. The findings related to motivation and the observation that informants who were not making many changes knew what healthy eating entailed but were not ready to make significant changes to their eating behaviours, support the assumptions of motivational approaches presented in the literature review. Overall, these findings present new insights into the role of motivation and the different types of motivation in the process of making and maintaining dietary changes, and support the importance of considering individuals' dispositions toward change when trying to influence them to modify their behaviours. 5.2.4. Making Decisions To Find A Balance Instead of "Complying" The findings diverge from the traditional literature in terms of expectations for compliance or adherence to health professionals recommendations. As opposed to conforming to the old medical model in which "experts" decided what individuals should do and expected them to do it, the findings indicate that informants were active decision makers with respect to the changes they made to find a balance. The findings support the literature which identifies that individuals weigh competing values and/or considerations when deciding what aspects of health professionals' recommendations they will follow (Janas, 1993; Donovan, 1995; Butler et al., 1996). For example, informants decided what lifestyle modifications to focus on and what changes to make within that focus. This finding is 184 D I S C U S S I O N congruent w i t h Janas and others' (1993) observation that hypercholesterolemic adults developed and used dynamic and idiosyncratic "game plans" to guide their dietary change efforts. These game plans guided individuals' decisions w i t h respect t o choosing foods, prepar ing meals, seeking informat ion, moni tor ing progress and judg ing success. Similarly, whi le informants were aware o f doctor 's and diet i t ian's recommendat ions, they also t o o k in in format ion from other sources (such as the media, family, and friends) and then combined the in format ion w i t h what they already knew in order t o construct their o w n understanding o f a l ip id- lower ing lifestyle. Thus, the findings support D o n o v a n ' s (1994) observat ion that individuals are not "b lank sheets" w h o await the instruct ions o f doctors, but are active participants w h o th ink very seriously about their t reatment regimen and make reasoned decisions about their treatment that can be quite different from the treatment plan advised by the doctor. Ano ther example o f the importance o f informants ' decisions relates t o the factors and considerations that influenced their food choices in various situations. These complex factors and considerations were similar to those described in the l i terature review, inc luding personal preferences fo r taste and convenience, the preferences o f others, and f o o d availabil i ty. Ano the r impor tant consideration was f o o d appropriateness. Un l i ke Hochbaum's (1981) bel ief that f o o d choices are of ten only moderately influenced by broad and vague not ions about what is supposed to be healthful, f ood appropriateness was a major considerat ion in many situations because o f in formants ' desire to lower their l ip id levels. However , despite the importance o f f o o d appropriateness when making food choices, other considerations were no t defeated by health professionals' expectations that they should comply w i t h diet prescript ions. Instead, 185 D I S C U S S I O N diet prescript ions were balanced w i t h personal definit ions o f "en joy ing l i fe " and wha t was "reasonable," as we l l as other priorit ies. The importance o f personal decision making supports the findings o f a study that examined the experience o f l iv ing w i t h insulin dependent diabetes (Hernandez, 1995). Hernandez reported that the individuals in her study saw themselves as active decision makers w h o rejected health professionals' pr imary goal o f "establishing glucose con t ro l . " V iewpo in ts expressed by individuals o f that study (e.g., t ry ing to fit diabetes in to their l ives, instead o f conforming their lives to fit the diabetes, and focusing on the needs and demands o f their bodies, instead o f focusing on the diabetes regimen) were similar t o the v iewpoin ts expressed by informants o f this study. W i t h the addit ion o f the findings presented here, i t is clear that individuals are making their o w n decisions regarding their behaviours and are less interested in b l indly " c o m p l y i n g " w i t h prescribed regimens. 5.2.5. Helpers and Barriers to Dietary Change The findings present many factors wh ich influenced the informants ' dietary change efforts. Factors identi f ied as helpers increased informants ' mot ivat ion, and prevented sl ipping or p romoted get t ing and/or staying on track. O n the other hand, factors ident i f ied as barriers reduced in formants ' mot ivat ion, and promoted slipping or prevented staying o n track. M a n y o f the intervening factors identif ied by informants are reported i n the l i terature, inc luding the degree o f mot iva t ion (Bruhn, 1988), the extent t o wh ich personal meaning fo r mak ing changes is established (Baker and Stern, 1993), the influence o f previous f o o d preferences and/or eating behaviours on the acceptability o f new behaviours and responses to temptat ions (Curr ie etal., 1991, Iszler etal, 1995), the role o f receiving feedback (McConaghy , 1989; Barnard et 186 D I S C U S S I O N al, 1995), and the role o f the sociocultural environment in terms o f whether other people are support ive and/or whether appropriate foods are available (Sallis and Nader, 1988; Baghurst , 1992; Wr igh t , 1995). Wh i le the sample was too small to make firm conclusions, there was evidence that gendered l i fe stages and social roles (such as mother ing, fathering and spousal roles) also inf luenced informants ' efforts to make dietary changes. The findings support Dev ine and Olson's ( 1 9 9 1 ; 1992) observations that women 's perceptions o f their appropriate social roles (especially their caretaking responsibilities fo r their chi ldren's health and nut r i t ion) appear to be strong mot ivators o f their dietary behaviour. There is less pronounced support fo r Johnson's (1991) observations that spousal roles influence individuals ' efforts to make dietary changes. She reported that many men recovering f r o m a heart at tack considered the modi f ica t ion o f their l ifestyle to be a jo in t venture between themselves and their spouses. W o m e n , on the other hand, tended to make lifestyle changes independently w i t h o u t invo lv ing their spouses t o the same extent as the men, t o o k sole responsibil i ty fo r their dietary changes, and were generally reluctant to make changes they thought might negatively affect their families. I n the study presented here married men and w o m e n were more l ikely t o make changes fo r themselves, regardless o f whether their spouse made accompanying changes. Perhaps this difference is related to the fact that several men in this study indicated that they prepared most o f the meals at home or shared this task w i t h their spouse or partner and that several o f the w o m e n indicated that their husbands prepared at least ha l f i f not most o f the meals at home. Another possible explanation fo r the difference is that Johnson's informants had experienced a heart attack wh ich is considerably more traumatic than having h igh b lood 187 D I S C U S S I O N l ip id levels and may lead to greater mot ivat ion on the part o f wives t o embark o n a " jo in t venture" approach w i t h their husbands. Overal l , the f indings support the importance o f various intervening factors, however, the var ia t ion among informants w i t h respect to the directional impact o f some factors requires fur ther consideration. For example, informants' starting point on the unhealthy t o healthy eating behaviour cont inuum was either a helper o r a barrier regardless o f w h i c h end informants were at. The variable directional impact o f intervening factors among informants emphasizes the importance o f not making assumptions about factors w h i c h influence each indiv idual 's ef fort t o make changes. K n o w i n g about potential intervening factors is beneficial, but this knowledge cannot be used by nutr i t ion educators unt i l they discover w h i c h factors are impor tant t o the individuals they are w o r k i n g w i t h and h o w these factors inf luence that person's part icular change efforts. 5.2.6. Dev ised C o p i n g Strategies The coping strategies informants devised in response to var ious intervening factors are similar t o the approaches and strategies Janas's (1993) participants used fo r coping w i t h confl icts between food-related considerations. For example, some informants were determined to achieve desirable outcomes and prevented slipping by " n o t mak ing except ions" and/or "avo id ing tempta t ion" (i.e., Janas's compliance approach). Others were more aware o f "d imin ish ing returns" fo r their efforts and did not compromise or deny themselves t o the extent that there was l i t t le enjoyment left in their l ives (i.e., Janas's accommodat ion approach). Despite the similarities, several differences are also apparent. Un l i ke Janas's assignment o f different coping strategies to the t w o approaches, the coping strategies o f 188 D I S C U S S I O N in formants in this study seemed to be more universal. For example, Claudia's determinat ion t o achieve desirable results meant she often used some o f the strategies included in Janas's compliance approach, such as implementing dietary restrictions w i thou t concession, using foods that " f i l l u p " and restr ict ing her contact w i t h tempt ing or challenging situations. However , she also used strategies included in Janas's accommodat ion approach, such as mak ing concessions in dietary restrictions (i.e., not denying self and a l lowing treats occasionally). In formants ' feelings o f resentment and/or being too control led w h i c h were associated w i t h having t o " w a t c h " and " th ink " about what they ate support Ciald in i 's (1985) observations about the " r igors o f th ink ing. " Devised strategies (such as cont ro l l ing f o o d availabi l i ty) made i t easier fo r informants to make and maintain changes because, according to Cialdini , i t of fered a w a y to avoid the " r igors o f cont inuing thought " o r "avo id the real labour o f t h ink ing " (p. 147). 5 .2 .6 .1 . T h e I m p o r t a n c e o f G e t t i n g Feedback Get t ing feedback to find out whether changes were making a difference was an impor tant intervening factor o f the change process because i t enabled informants to evaluate their outcomes and efforts in order to make decisions about h o w to proceed. This observat ion supports other findings in this area. Fo r example, McConaghy (1989) found that individuals thought experiencing the posit ive effects o f dietary change o n health and w e l l -being was the most important factor w i t h regard to the maintenance o f dietary change. Similarly, Johnson (1991) reported that individuals recovering f r o m heart attacks sought feedback in order to obtain p r o o f that they were recovering f r o m the heart at tack and 189 D I S C U S S I O N indicated they w o u l d give up t ry ing to adjust i f they saw no signs o f progress. A difference w i t h these studies, is that informants in this study did not have to necessarily achieve desirable outcomes in order to maintain new eating behaviours, but only had to perceive that they w o u l d obtain desirable outcomes in the future. 5.2.6.2. Allowing Treats Versus Slipping or Relapsing The dist inctions made between not making exceptions and not denying oneself contr ibutes to the discourse on relapse. The findings support B r o w n e l l and colleagues' d ist inct ion between lapses and relapses, w i t h lapses referr ing to slips and mistakes that may or may not lead t o a relapse ( in Neumark-Sztainer and Story, 1996). However , the findings do not support their bel ief that lapses are situations " i n wh ich a dieter consumes f o o d that is not w i th in a prescribed eating p lan" (p. 65). Fo r some informants, having occasional treats was not a slip o r " lapse" because i t was not a mistake. Instead, a l lowing a treat was a conscious decision w h i c h helped them "stay on the diet the rest o f the t ime. " Us ing terms such as lapse and relapse t o describe all events in wh ich inappropriate foods are consumed or inappropriate behaviours occur is misleading because o f the negativi ty o f the words . Lapse is defined as a fal l , slip o r mistake, whi le relapse is defined as fal l ing back in to evil . In formants i n this study did not v i e w a l lowing treats as a negative event, but as a strategy to help them make changes and maintain new behaviours. 5.2.6.3. Incorporating Changes Into a Lifestyle The finding that incorporat ing changes into a lifestyle made i t easier f o r informants to maintain new behaviours is congruent w i t h Johnson's (1991) observat ion that individuals w o r k t o w a r d "at ta in ing mastery" so that new behaviours can be per formed effort lessly and 190 D I S C U S S I O N without consideration. As noted by Johnson, knowing that they had incorporated changes into a lifestyle was very gratifying for some informants because it demonstrated that they could make changes and that changes were not difficult to achieve (provided they made a series of little changes over a period of time). While "attaining mastery" was the final stage of the adjustment process following a heart attack, incorporating changes into a lifestyle did not signal the end of the process of making dietary changes. Indeed, incorporating changes represented the final stage of making a specific change, but making dietary changes was an ongoing process that continued for years. Consequently, even though informants incorporated a few changes into a new lifestyle, most of them were still trying to make other changes and/or were starting to think about new changes they could also make. 5.3. S u m m a r y o f I ns igh ts The insights into the process of dietary change which are provided by this study are summarized below. • The findings emphasize the importance of recognizing interindividual variability with respect to how lipid levels respond to dietary changes and that individuals will always have uncertainties regarding the value of lifestyle modifications to lower blood lipid levels. • The findings provide a theoretical framework for understanding the process of lipid-lowering dietary change from the perspective of hyperlipidemic adults undergoing such change. • The conceptual model provides insights into individuals' dietary change efforts: -being resistant or willing to initiate and/or maintain the change process is 191 D I S C U S S I O N inf luenced by dr iv ing factors, such as being mot ivated, resolv ing t o making changes, and various personal circumstances -mot iva t ion is established in a process involv ing: a) being concerned about having h igh b lood l ip id levels; b) f inding personal meaning or a mot ive fo r mak ing behavioural changes; c) perceived abil i ty to make changes; d) establishing a posit ive att i tude; and e) past outcomes -mak ing changes is a dynamic process o f f inding a balance between enjoying l i fe and making enough changes -the process involves active, ongoing decision making in terms o f a) choosing a focus and determining what is reasonable; b) the value or meaning g iven to enjoying l i fe; and c) the perceived value o f mak ing changes in l ight o f the outcomes achieved and efforts required -the process involves compromising w i t h respect to enjoyment o r mak ing changes in order to achieve balance in certain situations - incorporat ing new behaviours into a lifestyle does not end the process o f mak ing changes • The findings suggest that individuals' dispositions t o w a r d change inf luence the extent to wh ich they find personal meaning and resolve to make changes. • The findings emphasize there are differences among individuals in terms o f the direct ional impact o f intervening factors. • The findings suggest that " lapse" and "relapse" are not accurate terms t o describe the inclusion o f inappropriate behaviours/foods. 192 D I S C U S S I O N • The findings confirm that a) individuals are at multiple stages of change at any given time because of the different behaviours, food components and foods involved and b) the action stage varies over time as individuals gain experience with making changes. • The findings support recent concerns that the Stages of Change framework may not be sufficiently comprehensive to encompass the dietary change process as a whole. • The findings emphasize that a multi-theory approach is necessary to adequately explain the complex process of making dietary changes. Overall, the conceptual model presented here is an important addition to the discourse on the process of dietary change because it provides a theoretical framework that describes the factors which constituted and influenced certain individuals' dietary change efforts. The implications of these findings for research and practice are considered following a brief examination of the study's limitations. 5.4. L imi tat ions of the Research The main limitation of this study is that the findings were generated from the experiences of a fairly homogeneous group of well-educated, middle class adults who shared the dominant Canadian culture. Therefore, it is not surprising that some intervening factors reported by others were not evident in this study. For example, food costs are often identified as a barrier to healthy eating (McAllister etal., 1994; Wright, 1995), however, food costs as a barrier to making and maintaining changes was only mentioned by one informant in relation to the type of restaurants which provide healthier food choices and/or are amenable to accommodating special requests. The group was also homogeneous because informants were 193 D I S C U S S I O N recrui ted from the same l ip id clinic and therefore were exposed to similar educat ion regarding lifestyle modi f icat ion. Furthermore, most o f the informants were either maintaining changes or were in the midst o f making changes. The homogeneity and size o f the sample meant that some concepts o r aspects o f the change process did not reach saturation. For example, there was very l i t t le data about "g i v ing u p " the process o f making changes. A lso, al though there were some variat ions w i t h respect t o ethnicity, cul tural background, life-stage, social role, and fami ly h istory o f C H D , i t was di f f icul t t o make firm inferences about the influences o f these factors because o f the small sample size and the small number o f individuals in each category. Theoret ical sampling w i t h increased at tent ion to cultural, social role and life-stage variations may have prov ided greater elaborat ion, refinement, and clari f icat ion o f unsaturated categories. The small and homogeneous sample wh ich was purposively selected also precludes generalizing the findings to others. However , generalizing findings is not a major goal w i t h i n the construct iv ist paradigm or when using qualitative methods because o f the assumption that human actions and understandings cannot be separated from their context. Instead, M o r s e and Johnson (1991) maintain that findings o f grounded theory have " theoret ical general izabi l i ty" in that the theory or model developed "should be applicable t o others w h o experience the same condit ions ... (and) the substantive theory may give rise to fo rmal theory" (p. 9) . Another l imi ta t ion was that the findings depended o n the truthfulness and accuracy o f the in formants ' accounts o f their experiences. There is potent ial fo r bias in self-reports o f eating behaviours and dietary change not only because some informants may recall features 194 D I S C U S S I O N that depict their behaviour as socially desirable (Si lverman, 1993), but also because their self-reports cou ld be affected by what they thought I wanted to hear ( M a y and Foxcro f t , 1995). Fur thermore, Sparks and colleagues found that people seem to judge their intake o f "unheal thy" foods as lower than that o f the average person and may repor t h igher- than-average consumpt ion o f healthy items ( in Raats and Sparks, 1995). Therefore, there is evidence t o suggest that what people actually " reca l l " is mot ivated by some sort o f w ish to present themselves in a favourable l ight relative to others (Raats and Sparks, 1995). Wh i le such tendencies are a potential l imi tat ion o f the study, several precautions should have minimized the occurrence o f such bias. First, I maintained that I was interested in their experiences o f the process o f dietary change and focused the questions on how they were mak ing changes. I focused on the phenomenon o f dietary change and d id not express an interest in h o w "compl ian t " they were to the l ip id- lower ing diet p romoted by the L i p i d Clinic. Second, I d id not outward ly judge their beliefs or behaviours. Final ly, personal eating behaviours were explored w i thou t revealing h o w " w e l l " other informants in the study fo l l owed a l ip id- lower ing diet. Regardless o f such potential l imitat ions, the insights generated by this study are valuable fo r improv ing our understanding o f the process o f dietary change. 5.5. Implications For Research This study deals w i t h the experiences o f adults making dietary modi f icat ions t o lower their b lood l ip id levels. The conceptual model constructed il lustrates a theoret ical framework o f the process o f l ip id- lower ing dietary change. Other researchers may find that i t can also be applied to individuals l iv ing w i t h diabetes or those in weight management programs. B y presenting a more adequate representation and deeper understanding o f the process o f dietary 195 D I S C U S S I O N change, the conceptual model can also be used as the basis fo r fur ther research examining the process o f dietary change and can provide a theoretical basis fo r the development o f nut r i t ion educat ion programs designed to promote lasting eating behaviour modi f icat ion. However , fur ther research that attempts to ver i fy this mode l and explore the similarit ies or differences among other populations is also required. Others have noted that those w i t h a higher educational level or in a higher occupational g roup are more l ikely to make a greater number o f dietary changes than the lower educational and occupat ional groups, and appear to be influenced to some extent by different factors w h e n considering making dietary change (McConaghy, 1989). Consequently, research w i t h different populat ions, such as individuals f r o m lower socioeconomic status, may reveal other factors w h i c h influence the process o f dietary change or other dimensions o f the factors presented here. Aspects o f the model should also be examined w i t h individuals w h o have teenage chi ldren l iv ing at home as this populat ion was not represented by the informants o f this study. Wh i le the f indings provide several insights wh ich advance our understanding o f the process o f dietary change, many important questions remain. M o r e research is needed to explore or better understand: • the process involved when individuals decide to start mak ing changes • the process o f becoming resolved to make changes • h o w different types o f mot ivat ion influence individuals' dietary change efforts • the implicat ions o f being at mult iple stages o f change at the same t ime f o r dif ferent eating behaviours • the different stages people go through once they begin making changes 196 D I S C U S S I O N • w h y some individuals experience w ider fluctuations w h e n sl ipping and others experience smaller fluctuations • whether o r not individuals redefine enjoying l i fe as the process o f change continues and h o w they do so • h o w individuals devise coping strategies • h o w the dietary change process differs fo r individuals w h o "g ive u p " • apparent gender differences w i t h respect to t ry ing harder o r sl ipping i f desirable outcomes are not achieved • the perceptions people have about health professionals' compliance expectations Long i tud ina l research investigating variations among individuals, such as their disposit ions towards change, their definit ions o f enjoying l i fe, or the nature o f their decisions in response to feedback, may fur ther increase our understanding o f the process o f dietary change. However , before more research is conducted to explore the process o f dietary change, perhaps the g r o w i n g body o f independently developed substantive theories about the indiv iduals ' f o o d choices (Furst et al, 1996), the process o f mak ing eating behaviour changes (Janis, 1993; Janis et al, 1993; Hernandez, 1995; Janis et al, 1996), and perceived personal and social barriers to long te rm dietary maintenance (Wr ight , 1995) should be integrated in order t o construct a denser and more complete understanding o f individuals ' experiences w i t h dietary change. A l though the isolated studies mentioned here are informat ive, Jensen and A l len (1996) l iken them to pieces o f a j igsaw puzzle because indiv idual ly they do not contr ibute signif icantly to a fu l l understanding o f the phenomenon o f mak ing dietary changes. Consequently, some f o r m o f "meta-analysis" should be applied to these qual i tat ive studies. 197 D I S C U S S I O N Whi le meta-analysis techniques are used to combine and analyze the results o f previous reports, they are tradit ional ly used to address quanti tat ive research questions. Nonetheless, suggested methods and criteria fo r conduct ing a r igorous "meta-synthesis" o f quali tat ive findings are beginning to emerge in the l i terature (Jensen and A l len , 1996). Overal l , the a im o f meta-synthesis is not to average findings, but to compare studies in order to create a hol ist ic interpretat ion o f the phenomenon. Whi le a meta-synthesis o f findings pertaining to the process o f dietary change is a complete study in and o f itself, such a large under tak ing is warranted n o w that several studies have explored individuals ' experiences w i t h making dietary changes and that guidelines fo r conduct ing such a study are beginning to emerge in the l i terature. Such a study w o u l d not only help nut r i t ion researchers and educators understand indiv idual experiences, but w o u l d also help them recognize patterns and c o m m o n experiences that are part o f human responses to making changes (Morse and Johnson, 1991). A meta-synthesis o f findings w o u l d help researchers construct a broad and strong theory o f dietary change that considers bo th psychological and socioenvironmental factors in a holist ic manner and takes in to account the perspectives o f individuals making changes. Such a theory w o u l d then prov ide nut r i t ion researchers and educators w i t h a more complete understanding o f complex eating behaviours and better equip them to help individuals make reasoned decisions about health-related behaviours. 5.6. Implicat ions For Practice Whi le some believe nutr i t ion education w i l l be a major component i n health p r o m o t i o n as w e seek t o keep people we l l rather than merely treat the sick (Anderson, 1994), the value o f nu t r i t ion education w i l l be questioned i f we are unable to p romote long- te rm changes to 198 D I S C U S S I O N eating behaviours. There is an abundance o f in format ion in the l i terature fo r nu t r i t ion educators about elements wh ich contr ibute to the effectiveness o f nu t r i t ion education, and pract ical approaches, t ips, o r strategies to promote dietary modi f icat ion. F o r example, the l i terature identif ies the importance o f a) promot ing the voluntary adopt ion o f f o o d - and nutr i t ion-related behaviours that are conducive to health and wel l -being, b ) p romot ing the development o f skills to support the acquisit ion o f new behaviours, c) having individuals define the behaviour that is to be changed, d) prov id ing opportuni t ies f o r individuals to practice behaviours, e) prov id ing external posit ive support and reward ing the posit ive steps t o w a r d goal achievement, and f ) helping individuals pr ior i t ize the changes that must be made (Caggiula, 1989; N C E P , 1994; Contento etal, 1995). However , u t i l iz ing these elements may not be sufficient to help individuals achieve desirable outcomes, especially w h e n l i t t le is k n o w n about h o w individuals actually make changes (Ho tz et al, 1995). The findings o f this study can fur ther help nut r i t ion educators understand h o w individuals perceive the process o f dietary change and make dietary changes w i th in the context o f their everyday lives. In formants in this study were concerned about their l ip id levels, but they also had to cope w i t h all the pressures o f l i fe and balance their o w n preferences, capabilit ies, pr ior i t ies and desires t o enjoy l i fe w i t h making enough changes to achieve desirable outcomes. I n order to find a balance, they were constantly making decisions about what they should eat o r do in var ious situations. Furthermore, fo l low ing evaluation o f outcomes and efforts they were mak ing decisions about whether to continue w i t h the process o f mak ing changes. I n accordance w i t h this decision-making role, the findings conf i rm that expect ing individuals to comply w i t h diet prescriptions is out o f place in nut r i t ion education (Donovan , 1995). Wh i le 199 D I S C U S S I O N individuals sti l l need to make enough changes in order to achieve desirable results, prescribing dietary modi f icat ions and operating w i th in tradit ional compliance or adherence relationships is not an effective w a y fo r nut r i t ion educators to promote dietary modi f icat ion. T o be in a better posi t ion to help clients, nutr i t ion educators should not ask " H o w can w e best help people make changes?" but should ask " H o w can w e best help people make decisions about mak ing changes?" This observation reflects the reorientat ion o f nut r i t ion educat ion practice w h i c h has been occurr ing in recent years (Botelho and Skinner, 1995; Hernandez, 1995; No lan , 1995; Bu t le r et al, 1996). Nu t r i t i on educators are recognizing that i t is not their responsibi l i ty t o make clients change behaviours; rather i t is their responsibi l i ty t o i n f o r m or influence cl ients' decisions whi le leaving the decision about the goal and methods fo r change to the client. A n awareness o f h o w individuals undergoing change conceptualize the process is also essential t o the development o f nut r i t ion education programs that enable nut r i t ion educators to enhance mot iva t ion and in fo rm or influence individuals' decisions. Just as the informants in this study were concerned about f inding a balance between enjoying l i fe and mak ing enough changes, nu t r i t ion educators are acknowledging that individuals do not focus exclusively on one or t w o physiological parameters (such as b lood l ip id levels o r b lood glucose levels), but are concerned about their lives as a whole (Hernandez, 1995). The findings also emphasize that individuals are different w i t h respect to dr iv ing factors or mot ivators, goals o r desired outcomes, as we l l as the intervening factors wh ich influence the process o f change; thereby suggesting that the ways in wh ich decisions can be informed or inf luenced may also vary among individuals. Thus, nut r i t ion educators should not only present educational in fo rmat ion 200 D I S C U S S I O N or self-care messages w i th in the context o f individuals' exist ing mot ivat ional f rameworks (Hochbaum, 1981 ; Baker and Stern, 1993), but should also ask clients questions that w i l l help them describe their personal experiences w i t h dietary change. The conceptual model developed in this study suggests some areas where in format ion w o u l d help nu t r i t ion educators understand h o w individuals conceptualize the change process. These areas include: a) the extent to w h i c h individuals are concerned about their condi t ion and mot iva ted to make changes; b ) the extent to wh ich individuals f ind personal meaning and resolve t o make changes (i.e., their disposit ions t o w a r d making changes); c) indiv idual 's pr ior i t ies in terms o f the value and meaning they give to enjoying l i fe; d) the relevance and direct ional impact o f intervening factors; e) h o w individuals interpret cycles o f sl ipping and get t ing back on t rack; and f ) the strategies w h i c h help individuals f ind a balance that facilitates mak ing changes wh i le sti l l enjoying l ife. Hav ing a better understanding o f individuals' personal experiences w i t h dietary change w i l l help nut r i t ion educators be in a better posi t ion t o i n fo rm and influence their cl ients' eating behaviours and help them make informed decisions about behaviour change processes. Overal l , the conceptual model presented here w i l l help nut r i t ion educators understand h o w hyperl ipidemic adults conceptualize the process o f dietary change because i t identif ies factors w h i c h consti tute and influence the dietary change process. N u t r i t i o n educators could also use the model as a guide to help them discuss the principles o f the dietary change process w i t h clients. F o r example, by describing h o w other people have experienced the change process, nut r i t ion educators could a) emphasize that dietary change is a process o f mak ing small changes over t ime, b) explore h o w clients define enjoying l i fe and h o w that may influence their change efforts, c) indicate that cycles o f sl ipping and get t ing back on t rack are 201 D I S C U S S I O N c o m m o n and that sl ipping should not always be v iewed negatively, and d) prov ide suggestions about ways to get back on track. 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(1973) Diet Therapy of Diabetes: An Analysis of Failure. Annals of Internal Medicine 79(3) : 425-434. Wr igh t , C.W. (1995) Social Barriers to the Maintenance of a Very Low Fat Cardiac Diet: A Qualitative Study. Unpubl ished thesis, Hal i fax, N o v a Scotia. 214 A P P E N D I C E S A P P E N D I C E S A p p e n d i x A : R e c r u i t m e n t No t i ce HAVE YOU BEEN TOLD YOUR BLOOD CHOLESTEROL LEVEL IS TOO HIGH? ARE YOU TRYING TO CHANGE THE FOOD YOU EAT TO LOWER YOUR CHOLESTEROL? ...HERE'S AN OPPORTUNITY FOR YOU TO TALK ABOUT WHAT YOU'RE GOING THROUGH A s t u d y i s b e i n g c o n d u c t e d t o u n d e r s t a n d w h a t a d u l t s w i t h h i g h c h o l e s t e r o l a c t u a l l y e x p e r i e n c e w h e n t h e y a r e t r y i n g t o m o d i f y t h e i r e a t i n g b e h a v i o u r s . T h u s , i n d i v i d u a l s w h o a r e t r y i n g t o c h a n g e t h e i r d i e t t o l o w e r t h e i r b l o o d c h o l e s t e r o l l e v e l s w i l l b e i n v i t e d t o t a l k a b o u t t h e i r e x p e r i e n c e s w i t h c h a n g i n g t h e i r e a t i n g b e h a v i o u r s . I n d i v i d u a l s w h o p a r t i c i p a t e i n t h i s s t u d y w i l l b e i n t e r v i e w e d a t l e a s t o n c e , b u t m a y b e a s k e d f o r o n e o r t w o a d d i t i o n a l i n t e r v i e w s . E a c h i n t e r v i e w w i l l l a s t b e t w e e n 3 0 a n d 9 0 m i n u t e s . I n t e r v i e w s a r e s c h e d u l e d t o b e g i n i n O c t o b e r a n d w i l l b e c o n d u c t e d a t t i m e s a n d p l a c e s t h a t a r e c o n v e n i e n t f o r t h e p a r t i c i p a n t s . T h e r e s e a r c h e r e x p e c t s t h a t t h e f i n d i n g s o f t h e s t u d y w i l l h e l p i d e n t i f y t h e m a j o r c o n c e r n s a n d b a r r i e r s i n d i v i d u a l s c o n f r o n t w h e n m a k i n g c h a n g e s t o t h e i r d i e t s . U n d e r s t a n d i n g t h e p r o c e s s o f d i e t a r y c h a n g e m a y i m p r o v e n u t r i t i o n e d u c a t i o n p r o g r a m s a n d m a y h e l p o t h e r i n d i v i d u a l s d i s c o v e r w a y s o f d e a l i n g w i t h d i e t a r y c h a n g e i n o r d e r t o r e d u c e b l o o d c h o l e s t e r o l l e v e l s . If y o u a r e i n t e r e s t e d i n t a k i n g p a r t i n t h i s s t u d y O R h a v e q u e s t i o n s a b o u t t h e s t u d y , p l e a s e c o n t a c t : A L Y S O N E A T 822-6874 215 Appendix B : Screening Questionnaire Recruitment Screening Questionnaire Name: Telephone: 1. Where did you here about this study? a) from a dietitian, who? : b) from poster 2. How old are you? 3. Do you know your cholesterol level? a) no b) yes, what is it? 4. How long ago were you diagnosed with high cholesterol? 5. Have you been trying to change your diet to lower your cholesterol level? a) no b) yes, for how long have you been trying to change your diet? 6. Are you currently taking any cholesterol-lowering medication? a) yes, b) no, have you taken cholesterol-lowering medications in the past? 7. Do you have any other diet-related medical conditions (e.g., diabetes)? a) yes, b) no 8. Are you under medical care for conditions other than high cholesterol? a) yes b) no 9. Have you ever had a heart attack or other signs of heart disease? a) yes, b) no 10. What is your current living situation? A P P E N D I C E S Appendix £: Preliminary Interview Guide •get the informant talking: • Can you tell me a bit about yourself: -Where you were bom? -Can you tell me about your family or the people you live with? -What do you do for a living or what you spend most of your time doing? -What are some of your interests or hobbies? •introduce the topic of high cholesterol: • Can you tell me about how you found out you had high cholesterol? -When did you find out you had high cholesterol? -How did you find out you had high cholesterol? -who initiated the test or who told you that you have high cholesterol? -Why were you tested? • What was your cholesterol level the last time you had it measured? • We use the term "high cholesterol" a lot, but we don't always explain what it means to us and it can mean different things to different people. So I was wondering what the term "high cholesterol" means to you? • How do you feel about having high cholesterol? • What has having high cholesterol meant for your life? •introduce the process of [dietary] change: • Can you tell me about how knowing you have high cholesterol has affected you, or changed any of the things that you do? • Can you tell me about the changes you're making or trying to make? • When did you start attempting this (these) change(s)? • Are you trying to make changes to the foods you eat? (What about eating out?) • How have you gone about making changes? What have you been doing, or what changes do you think you should be making? • What prompted you to start making changes? • Were there any other changes happening in your life around the same time? How did these events affect the changes you've told me about? • Can you tell me about some of the things in your experience that help you to eat the way you want to? • Have you experienced (Do you anticipate) any benefits because of the changes? • Can you tell me about some of the things in your experience that keep you from eating as well as you would like? • Have you experienced (Do you anticipate) any problems because of the changes? 220 A P P E N D I C E S A p p e n d i x F : L a t e r I n t e r v i e w G u i d e • I'd like to explore your experiences with having high cholesterol, as well as your experiences of making changes to lower your blood cholesterol level. • Can you tell me a bit about yourself? • Where you were bom? your family? your job? your interests/hobbies? •INTRODUCE THE TOPIC OF HIGH CHOLESTEROL: • Can you tell me about how you found out you had high cholesterol? • Why were you tested? Who initiated the test? Who told you? • How did you feel when you found out you have high cholesterol? • How do you feel now? • Do you have a family history of high cholesterol? • How would you say knowing you have high cholesterol has affected your life? • We often use the term "high cholesterol," but we don't always explain what it means to us and it can mean different things to different people. So I was wondering how would you explain the term high cholesterol to someone who doesnt know anything about it? • How would you evaluate or rate your health? • Has how you thought about your health changed since finding out you have high cholesterol? •INTRODUCE TOPIC OF CHANGE (DIET. PHYSICAL ACTIVITY. SMOKING. AND ALCOHOL): • Can you tell me about some of the changes you've been making in order to lower your blood cholesterol level? • When did you start attempting these changes? • Can you tell me how you found out about what you should be doing? • What motivated you or prompted you to start making these changes? • How did you feel when you were told you should make these changes? • How different would you say the way you eat now is from the way you used to eat before you found out you had high cholesterol? What is different? • How different is it from the "ideal" at the Lipid Clinic? Why? • Do you ever see yourself getting to that level? • How would you compare the satisfaction or enjoyment you get from the food you eat now vs. what you used to eat? • Was there anything else happening in your life around the same time you found out you had high cholesterol that may have affected the changes you've told me about? •FOOD COMPONENTS: • What factors do you consider when you're deciding what to eat or not eat? • You seem to be focusing a lot on (fat, sugar, etc.). Can you tell me why you're focusing on (xxx) or what information you received which caused you to be concerned about (xxx)? • Are there other things in food that you're concerned about? • Are you concerned at all about the different types of fat that are in foods? 221 A P P E N D I C E S (Append ix F cont inued) •HELPERS: • Can you tell me about some specific situations that you've experienced where you found it easy to eat the way you want to? • Probe for specifics: the place, social context, feelings and triggering events. •BARRIERS: • Can you tell me about some specific situations that you've experienced where you found it difficult to eat the way you want to? • Probe for specifics: Can you give me an example when was hard for you? • How do you respond, or what do you do when you're in a situation like that? • Explore eating out situations. • From what you have said and from what others have said it sounds like you have more control over what you eat when you're at home. - Can you tell me how you think "control" may play a role in your eating situations? • Can you give me an example of a situation where you had more control and then one where you had less control? •SOCIAL SUPPORT (if applicable): • Can you tell me a bit more about how your family or friends affect your efforts to eat well? • Do family members or friends make it easier or harder? -In what ways do they make it [easier/harder]? • What specific behaviours help? What behaviours create obstacles? • Are there supportive behaviours that family/friends could be doing that they currently fail to do? •CYCLIC PROCESS: • How has what you've said today about your eating changed over the years? • e.g., how is your eating different now from,6 months ago or a year ago? • Can you give me some specific examples of what was the same/different about what you did before? • How do you know or decide if what you're doing is making a difference? • Were the results from your last test higher or lower than before? • What do you think you might do differently if your cholesterol goes up. (again)? • Will you change what you're doing if your cholesterol goes down? • Do you have any goals for managing your cholesterol level? or Do you have any specific goals related to what you eat or your cholesterol level? • What keeps you motivated to maintain the changes you've talked about? OR What do you think prevents you from staying motivated? •WRAP-UP: • Is there anything else you can think of that we havent talked about or anything that I havent asked that might be important in terms of what you're doing or how you feel about having high cholesterol? • Have you thought of anything else that makes it easy, or difficult to eat the way that you want to? 222 A P P E N D I C E S (Appendix G continued) 224 A P P E N D I C E S (Append ix G cont inued) Study Context Several lifestyle behaviours are associated with being at risk for coronary heart disease (CHD). The emphasis of this study is the eating behaviours associated with this risk. I recognize that individuals initiate other lifestyle changes to reduce their risk for CHD, but the findings presented here concentrate primarily on the dietary change process. Other lifestyle behaviours are discussed as they relate to eating behaviours. Dietary Change Process The factors that contribute to and influence the dietary change process are illustrated in the accompanying model. The centre square contains the components which contribute to the dietary change process. This process involves cycles of making changes in order to find a balance between enjoying life and making enough changes to achieve desirable diet-related outcomes. The "change arrows" indicate that change is accomplished by making drastic changes or a series of little changes. Cycles of slipping (going back to old ways) and getting back on track are also part of the change process. Making Changes Dietary change is an experimentation process. The informants experiment with various changes in order to achieve a personally acceptable balance between enjoying life and making enough changes to achieve desirable results. Whether drastic changes or a series of little changes are made, the early stages of making dietary changes are characterized by having to watch or think about what is consumed. However, as time passes some individuals incorporate these new eating behaviours and/or food preferences into a new lifestyle. Changes which are incorporated into a lifestyle are performed unconsciously. Individuals who successfully incorporate changes, but still seek more desirable results, will continue the cycle by making new changes. In contrast to incorporating changes, cycles of slipping represent periods when individuals are not concerned about making changes to achieve desirable results. At these times, dietary change is not a priority and some individuals tend to go back to their previous eating behaviours. Getting back on track represents the transition to again being concerned about making changes to achieve desirable results. Finding A Balance The informants try to balance enjoying life on the one hand with making enough changes to achieve desirable results on the other. The value or meaning given to enjoying life relates to quality of life issues, such as the satisfaction, enjoyment, and pleasure obtained from life. For some informants, enjoying life involves not feeling deprived, not feeling like they are being controlled, not eating just for the sake of providing the body with fuel, not having to eat "crummy" food and not being worried about everything you eat. At times, this meaning of enjoying life can interfere with reducing the risk for CHD—that is, when making changes and enjoying life are viewed as mutually exclusive endeavours. Other individuals define enjoying life as being healthy or being able to do the activities they want to in life. This second approach to enjoying life can help with making changes that may contribute to reducing the risk for CHD. Making enough changes to "make a difference" or achieve desirable results is the second key component of rinding a balance. Individuals who place more emphasis on enjoying life may not make enough 225 A P P E N D I C E S (Append ix G cont inued) changes to achieve desirable outcomes. If achieving desirable outcomes is a goal for these individuals, they have to continue making more changes. On the other hand, some individuals make lots of changes, yet do not achieve desirable results. For these individuals, it seems that other factors besides making dietary changes may require attention (such as physical activity, medications, etc.). Finally, some individuals who are making enough changes to achieve desirable results recognize that there is still room for improvement and will continue the cycle of making more changes to achieve even more desirable results. As mentioned above, achieving desirable (diet-related) outcomes plays a role in finding a balance. Hyperlipidemic adults are seeking professional advice to find out what they have to do to lower their blood lipid levels and reduce their risk for CHD. Achieving desirable results, however, does not only refer to reducing or sustaining blood lipid levels. Finding personal meaning or a motive for making changes seems to be an essential aspect of achieving desirable results because it allows individuals to work towards achieving personal goals. Hence, achieving desirable results also refers to losing weight (and perhaps being able to wear the clothes one wants to), enhancing physical conditioning, and /or improving health (as demonstrated by feeling better, looking better and being able to do the activities one wants to). Finding a balance between enjoying life and making enough changes to achieve desirable results is a give-and-take process which involves compromising between what one would like to do or eat and what one thinks one needs to or should do in order to achieve desirable results. At times, some enjoyment is sacrificed to achieve desirable results. At other times, making changes to achieve desirable results are put off in order to enjoy life or make the best of a situation. For some, enjoyment is willingly sacrificed when gains or desirable outcomes are being achieved. However, once the loss of enjoyment outweighs the gains it may become a case of "diminishing returns" and some individuals stop trying to make new changes. Individual differences with respect to sacrificing enjoyment depends on the personal conception of "what is reasonable." Intervening Factors The process of dietary change varies from informant to informant due to several intervening factors. These factors also influence whether or not informants slip or are able to get back on track. Some of the intervening factors are indicated on the model with arrows directed toward the centre box. These factors include: 1) characteristics of the condition (e.g., "at risk" for CHD; symptoms are rarely experienced; an ongoing condition which requires lifestyle/behavioural changes; associated with uncertainty regarding the outcomes of making changes) 2) motivation (i.e., the presence or absence of an internal drive to engage in dietary change) -influences the overall likelihood of making changes -influences the relative weight given to enjoying life and making enough changes; affects the perceived acceptability of changes and the willingness to compromise -the degree of motivation is influenced by several factors: -beliefs and attitudes about having high blood lipid levels including feelings associated with the diagnosis and the perceived seriousness of the condition -the extent to which one makes up his/her mind to make changes (resolve) 226 A P P E N D I C E S (Append ix G cont inued) -perceived ability to make changes -past outcomes or feedback 3) past eating behaviours (includes food preferences) 4) other lifestyle behaviours (i.e., the extent to which making changes in other lifestyle areas (such as physical activity) influences the likelihood of making dietary changes) 5) personal characteristics (e.g., living situation; social role (mother, husband, etc.); age) 6) personal outlook (i.e., favourable or unfavourable views about having to make changes) 7) soeiocultural environment (e.g., societal preoccupation with health, fitness, and nutrition in conjunction with a culture which promotes self-rewarding and treating) 8) feedback (enables an assessment of the effort involved in making changes and the benefits or outcomes achieved) -inability to achieve desirable results -may "try harder" by making more changes -may "give up" or stop making changes (no returns for effort) -achieving desirable outcomes -inspired to try harder (want to achieve better results) -maintain the new behaviours (content with the results) -slipping or relaxing (desirable results or goals are achieved) 9) personal and environmental barriers Being away from home No self-control Food availability Food preferences (personal and of others) Changes in routines/Stress Unable to maintain motivation Feeling deprived/Missing foods Slipping/Unable to get back on track Wanting Foods/Making exceptions 10) devised coping strategies (i.e., ways of making changes easier to accomplish and/or ways to increase enjoying life while making changes to achieve desirable results) Controlling food availability (at • Not denying oneself home) Allowing treats Choosing a focus for changes Choosing foods with high taste value Not making exceptions Eating different foods (so not eating less food; not Making little changes (to minimize dieting) feeling deprived) Methods of Dietary Change Although not illustrated on the model, the various methods of dietary change were also investigated. Regardless of whether changes are drastic or gradual, informants use combinations of the following dietary change methods at home and away from home: A T H O M E ; • Eating Less Eating Foods Less Frequently Eating Foods In Smaller Amounts Eliminating Foods Completely Virtually Eliminating Foods (i.e., eating foods much less often and in smaller amounts) 227 A P P E N D I C E S (Append ix G cont inued) • Eating More Foods Naturally Low In Fat and/or Cholesterol Foods Naturally Low In Sugar or Salt Substituting Foods Lower-fat products to reduce fat intake Diet/unsalted foods to reduce sugar/salt intake • Altering The Method Of Preparation Removing/Trimming Visible Fat Using Non-Stick Cookware Using Lower-Fat Methods of Preparation A W A Y F R O M H O M E (In Restaurants/In Others' Homes): • Ordering/Choosing Carefully • Eating Selectively Using self-control when less in control of the food available and/or how it is prepared • Limiting the Frequency of the Event Summary The model and the information above capture the main commonalities among the informants I talked to with respect to the dietary change process. My main concern is that the findings represent the informants actual experiences. I look forward to speaking with each informant about their reactions to these findings and discussing whether or not the model explains their experiences. 228 A P P E N D I C E S A p p e n d i x H : D e m o g r a p h i c Ques t i onna i re Questionnaire (to be completed by informant) Name: - , , Address: ' ; Phone #: Date of birth: In what country were you bom? ; Cultural heritage: (e.g., British, Scandinavian, First Nations, etc.) Present marital status (check one): Single/Never married^ Married, Common-law/Partnered Separated/Divorced/Widowed Do you have any children? If yes, in what year(s) were they bom? What is your occupation? What is the highest level of education you have obtained?^ When were you first diagnosed with high cholesterol? When did you first come to the Lipid Clinic? Are you currently taking medications? If yes, please specify Do you have a family history of high cholesterol?_ Do you have a family history of heart disease? What is your height?, What is your weight? Do you have any other medical conditions related to diet? (e.g., diabetes, ulcerative colitis, etc.) If yes, please specify 229 A P P E N D I C E S Appendix I: Informants' Outlooks Regarding Diagnosis INFORMANT DIAGNOSIS O U T L O O K AND IT'S IMPLICATIONS Anne -she was not worried because it did not mean much to her -her concern grew as she found out about the consequences -it motivated her to make dietary changes and exercise more Bruce -it scared him and he was quite concerned -it motivated him to exercise more and make dietary changes Claudia -she was quite worried -it motivated her to make dietary changes Doug -he wasn't surprised because of his weight and eating habits -he made some changes, but always drifts back Grace -she was very worried at first because she had angina -it motivated her to make dietary changes Janice -she was more concerned about having high blood pressure and being at risk for diabetes -losing weight and having energy were also big concerns and motivated her to exercise more and make dietary changes Kevin -he was shocked, but thought he couldn't do much about it -new doctors convinced him to take drugs and quit smoking -he also worked on modifying his eating behaviours Matt -initially, he was not concerned because he lacked symptoms -higher lipid levels and his father's death increased his concern -it motivated him to exercise more and make dietary changes Nancy -she was not surprised because of her weight and family history -it motivated her to exercise more and make dietary changes Oliver -he became aware of the problem -it motivated him to exercise more and make dietary changes Richard -he did not consider it a real big factor and wasn't too concerned -it motivated him to make dietary changes to lose weight Steve -he did not recall it having any significant impact -he saw it was something he had to think about and look after -it motivated him to make dietary changes Tracy -she was a little surprised because she did not feel ill -initially it motivated her to exercise more Victoria -she was angry and did not think it was fair -it prompted her to make a few dietary changes 230 

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