From Volume 44, Issue 4, April 2017 | Pages 353-360
Providing dietary advice to our patients forms the cornerstone of prevention for many dental diseases. However, simply prescribing information is unlikely to bring about long-term behavioural change. This article explores the theory of health behaviour as well as ways in which we can ‘get the message across’.
Oral disorders affect 3.9 billion people worldwide,1 with it being well accepted that the majority of this disease is preventable. Primary prevention (preventing the onset of disease)2 forms the cornerstone of high-quality dentistry and, in primary dental care, there is an excellent opportunity to provide this owing to the generally healthy nature of patients seen. It is acknowledged that these ‘upstream approaches’ are cheaper and more effective compared with situations when disease onset has occurred.3,4
Diet has been closely linked to oral and general health. Within the dental setting, the vast majority of evidence has historically focused on its association with dental caries, although periodontal diseases and oral cancer are also linked to nutritional status.5,6
As well as taking a whole population approach by educating patients prior to the onset of their oral/general health diseases, susceptible patients must be identified early in the onset of their disease and given consistent, evidence-based information in a way in which the chance of initiating behaviour change is maximized.
This paper aims to explore:
Three types of health-related behaviour are described:7
There are many theories that help us understand, predict and guide health behaviours. Those that will be discussed briefly are:
Traditionally, health promotion/education has been delivered as clinician-led advice that is assumed to increase a patient's knowledge on risk factors/disease.
The KAB model is considered outdated and simplistic. Knowledge does not necessarily lead to a change in attitude and, further down the line, just because patients have the positive view to reduce their sugar intake, for example, they may still continue with their current routine and thus behaviour does not change.8
A prescriptive approach to dietary advice can also be seen as critical and intrusive, particularly on a topic that can already be very delicate to address. This may result in a defensive stance where resistance to change increases as does persistence of an unhealthy diet.9
This was first described by Rosenstock in 197410 following Hochbaum's work on uptake of tuberculosis screening in 1958.11 It is one of the older models in health psychology and is based upon two aspects of a patient's belief:
Combining the above beliefs is said to dictate the likelihood of a behaviour change. It suggests that there is an increased probability of behaviour change if patients consider themselves at high risk of a condition and that the benefits of the specific behaviour change outweighs the costs.
This was first described in 1975 by Rogers as a development of the HBM and has been expanded over the years.13 It states protection motivation (the intention to follow behavioural advice) is determined by two appraisal processes:
The theory of planned behaviour (TPB), proposed by Ajzen in 1991,14 was an expansion on the earlier theory of planned behaviour, described by Fishbein and Ajzen in 1975.15
The TPB is based on predicting behavioural intentions and considers three main factors that contribute to this:
It is important to note that the TPB focuses on the intention to change and that may not always translate across to behaviour change itself.
Developed by Bandura in 1986,17 the social cognitive model outlines a number of core factors influencing behaviour change. These are:
The Transtheoretical Model (TTM) was first proposed by Prochaska and DiClemente in the 1980s.18 It is most renowned for its application to smoking cessation but can be extended to other health behaviours. Part of the model describes ‘stages of change’ in five steps:
It is acknowledged that patients may not move through the stages in a linear fashion and relapse can be common, with multiple attempts before successful behaviour change is achieved (Table 1).19
| Health Behaviour Model | Possible Application to Dietary Advice |
|---|---|
| The Health Belief Model |
Perceived susceptibility: I am at high risk of dental decay. |
| Social Cognitive Model |
Perceived self-efficacy: I believe that I am able to increase the amount of fresh fruit and vegetables I eat during the day even if it means more regular shopping trips. |
| The Transtheoretical Model of Change |
Pre-contemplation: I have no intention of decreasing the amount of sugar I put in my tea |
There are numerous guidelines that the dental practitioner can consult explaining what information should be relayed to our patients regarding dietary advice. Individual guidelines will vary in their content depending upon what aspect of oral health they are focusing on. However, it is important that guidance does not contradict, as consistency of the message within the dental team is essential in order to avoid confusion amongst patients. Below is a list of guidance documents available to dental professionals referencing dietary messages as part of oral health promotion, with Table 2 summarizing a few:
| Guideline | Summary of Information Relating to Dietary Advice |
|---|---|
| Delivering Better Oral Health: An evidence-based toolkit for prevention | Key messages for healthier diets: |
| Consensus of the 7th European Workshop on Periodontology | Discussed the following advice as part of general health promotion and the potential for periodontal disease prevention/treatment: |
| Oral Health Promotion: General Dental Practice (NICE guidance) | All patients should be given dietary advice based on the ‘Delivering Better Oral Heath Guidance’. |
Changing behaviour in our patients should not, however, involve a purely prescriptive approach. Dental professionals should aim to empower and motivate patients to take control of their disease and oral health.
Developing a patient-centred approach to oral health promotion is not a new concept but is a focus of the recent NICE guidance, ‘Oral Health Promotion: General Dental Practice,’ published in December 2015.21 Guidance for individual approaches to behaviour have also been published in the NICE guidance ‘Behaviour Change: Individual Approaches’,24 and provide recommendations for groups who have a vested interest in behaviour change interventions, ranging from national bodies to staff working in health and social care services (Table 3).24 Whilst it is acknowledged that delivering dietary advice and making healthy eating easier for patients involves broader socio-economic factors, this article will discuss individual-level behaviour intervention.
| Recommendation | Possible Incorporation to Dietary Advice in General Dental Practice |
|---|---|
| Ensure interventions meet individual needs: |
Times when patients may be more receptive include significant events such as the birth of a child or sibling, after a recent health scare, loss of a tooth due to caries or periodontal disease, discovery of a white patch etc… |
| Deliver very brief, brief, extended brief and high intensity behaviour change interventions and programmes. | Dentists should be aware of local centres where patients can be ‘Signposted’ for further information, eg dietitians, general practitioners or local healthy eating clubs. |
| Ensure behaviour change is maintained for at least a year: |
Good record-keeping is essential to monitor the advice given, highlight risk areas, and provide reminders to follow-up at regular intervals. Modern computer systems usually have the ability to produce ‘pop up’ reminder notes and to set recall periods in line with NICE guidance. Dentists/DCPs should regularly review the dietary status of patients at all recall appointments.26 |
There are a variety of methods that dental professionals can utilize (in combination) to promote positive dietary habits effectively, in a way that motivates patients to take responsibility for their diet and improve their oral health. These methods include:
This is probably the most common form of evaluating a patient's dietary status and provides a snapshot of current behaviour. A six-step dietary counselling model has been described as:27
As part of taking a diet history/analysis, a 3-day diet diary should be given to the patient to fill in. Reflecting on the patient's dietary habits and providing feedback allows for tailored advice and goal-setting for the individual, resulting in an increased likelihood for change.
The dental team is in an excellent position to deliver very brief, brief or extended brief advice. These are defined by NICE24 as:
Depending on the setting and competency of the dentist or DCP, any of the above interventions can be provided in primary care.
Motivational interviewing (MI) is a patient-centred technique, first described by Miller in 1983.28 Whilst its initial application was for the treatment of substance abuse, in particular alcoholism, it is gaining interest in other areas of health promotion and prevention. This section aims to give an overview of the concepts behind MI and is by no means a comprehensive guide to the technique. A further source of information is the online resource.29
MI is simply described as a ‘collaborative conversation style for strengthening a person's own motivation and commitment to change.’30
Relating back to health behaviour therapy, MI has been closely linked with the TTM (Stages of Change model) as it is thought that MI can deliver the motivation to advance individuals through the various stages. Furthermore, whilst it can be seen as useful for patients at any point along the cycle, it is postulated that MI is a good technique to use with those who are at the precontemplation or contemplation stage where prescriptive techniques are known to be ineffective.30,31
MI has five core principles:32
The concept of MI extends beyond a series of core principles however. The ‘spirit’ of MI has been described by its pioneers and reinforces the need for an open patient-professional relationship. The key aspects to the spirit of MI are summarized in Table 4.33,34
| Motivation to change comes from the patient |
| It is the patient's task to identify and resolve his/her conflicting thoughts (eg wanting to eat healthily but enjoy food) |
| Direct persuasion is not an effective way of resolving conflicting thoughts |
| The counselling style is generally quiet |
| The practitioner's responsibility is directive in helping the patient change behaviour |
| The readiness to change is not a patient trait but rather a fluctuating product of interpersonal interaction |
| The patient-professional relationship should be seen as a partnership, respecting the patient's autonomy |
Access to smart-phone technology has been on the rise for the last decade and the majority of the western population is now well versed in its use. Delivering dietary advice as well as monitoring nutritional intake is now possible to aid individuals in maintaining or even instigating behaviour change.
The ‘Sugar Smart’ app developed by Public Health England allows you to scan the barcodes of different foods/drinks and translates the sugar content to the equivalent number of sugar cubes.35 This visual tool can be an effective way of motivating the consumer to pursue healthier alternatives. Dental practices can also use the app to develop waiting room displays and quizzes, raising awareness about the amount of sugar in common foodstuffs.
Another app developed by Public Health England called the ‘Easy Meal’ app provides healthier versions of favourite meals. It can be found on the ‘One You’ website, launched in March 2016.25 Patients can be informed of this website as a means of finding further information on healthy eating.
This article aims to explore not only the theories underlying health behaviours, but offers techniques and examples of ways in which the dental professional can engage patients to take responsibility for their dietary habits and ultimately their oral health. In order to provide patients with self-efficacy and encourage long-term behaviour change, moving away from a prescriptive model of information giving should be encouraged, thereby embracing the importance of the patient-centred approach.
