Nutrition and Cystic Fibrosis Module 4: Patient-centered Behavior Interventions

Learning Objectives Describe effective strategies for facilitating behavior change in patients. Discuss the impact of parental/care-taker life course on disease management and overall health of the pediatric CF patient. Describe appropriate culturally competent approaches to patient care.

Importance of Adherence to Nutrition Recommendations Strong link between weight-for-length/BMI and lung function Early intervention likely to provide best long-term outcomes for growth and survival Historically among CF pediatric population non-adherence to nutrition recommendations is high Dietary adherence closely related to Child mealtime behavior Parent-child mealtime interactions Knowledge level of nutrition and CF www.cff.org

Strategies to Promote Behavior Change Differential attention – parents/caregivers praise appropriate behavior, ignore inappropriate behavior Child Behavior Typical Parent Response Behavioral Change Taking bites Not Noticing Compliment child on eating Excess talking Instructing child to eat Feeding child Ignore child until they take a bite, then answer questions or engage in conversation Complaints such as not liking food or negotiating Coaxing, prompting Making meal items Ignore complaints and compliment child for eating foods Leaving the table Coax or instruct child to return Set rules about staying at the table during meals Guide back to table with little discussion Complaints of being full Coaxing, promoting, feeding Negotiate amount of food child will eat Set appropriate food intake expectations and meal length, and set rewards Adapted from Borowitz et al. Using Nutrition to Stay Healthy with CF presentation.

Strategies to Promote Behavior Change Contingency management – parents/caregivers establishing expectations along with positive and negative consequences Rewards – provide immediately after positive behavior Withhold reward for negative behavior Contracting – Written agreement between parents/caregivers and child outlining goals and consequences SMART goals – provide more accountability and measurability Specific Measurable Attainable Realistic Timely

Getting to the Goal Anticipated Results Broad Goals Specific Goals Weight gain ↑ kcal and fat intake Add 1 Tbs of butter to your oatmeal every morning Decreased malabsorption Take enzymes as prescribed Take enzymes before each meal or snack on 5 out of 7 days Improve vitamin D status Take vitamin D supplement as prescribed Take vitamin D supplement each morning before your bowl of oatmeal

Goal Setting Practice Rewrite the following goals to be more specific: Remember to take your acid pill Increase your activity over the next month Gain 2 pounds by the next clinic visit

Strategies to Promote Behavior Change See text Table 17.2 Behavioral strategies and application in CF nutrition. Consider… Culture aspects of nutrition education and counseling Life course of both child and parents/caregivers It can be difficult and may take a significant amount of time for parents/caregivers to reverse problem behaviors Parents/caregivers may need support themselves to help facilitate behavior change RDN provides education and assistance to parents/caregivers and child with these behavior change strategies May need referral to feeding program Work with other professionals on health care team, especially social worker Check in at each clinic visit and reinforce concepts

Considerations When Working with Patients and Families Aspects of food behavior and food environment What the RDN needs to know Example Availability What types of food are available both in the environment and economically? Note foods available from local food sources and their relative price Acceptability What items are accepted as food and under what conditions? Differentiate those foods preferred from those available but not preferred Selection Which foods are most commonly chosen for consumption, and who makes the food selection decisions? Differentiate those foods chosen consistently that make up a substantial part of overall intake Procurement How and where are foods obtained by household? Note foods obtained from grocery stores, home gardens, vending machines, restaurants, etc. Preparation How is food prepared before eating? Cooking and preparation methods for major foods consumed. Adapted from Table, Terry RD.

References Nutrition in Cystic Fibrosis, Yen and Radmer Leonard – Chapter 17 Cystic Fibrosis Foundation – www.cff.org Borowitz et al. - Using Nutrition to Stay Healthy with CF presentation Terry RD. Needed: A new appreciation of culture and food behavior. J Am Diet Assoc. 1994;94(5):501-503.