A visit to the dental office could be interpreted as an opportunity to provide patients with dietary advice and encourage change in behavior. Rising rates of obesity and chronic noncommunicable diseases, such as cardiovascular disease, diabetes, hypertension, stroke, dental caries, and some kinds of cancers, including oral cancer, have been directly related to diet and lifestyle patterns.1 Helping people to change their diet and lifestyle requires skills to change their everyday behaviors.
The majority of patients do not comply with clinicians’ suggestions to change their diet and lifestyle, especially when an advice-giving approach is used.2 However, dietary advice in the dental setting need not take a didactic approach, and motivating and facilitating dietary change should be an important role of the dental health professional. Using effective interpersonal skills can result in improved patient satisfaction, while non-effective communication usually results in barriers to behavior change. 3
the Stages of change
In the literature there are numerous models and theories that may be applied to changing dietary behavior. Stage-based approaches to changing dietary behavior (or other lifestyle behaviors) focus on the decision-making process of the individual. The stage-based approach suggests that individuals are at various stages on a cycle of “readiness to change” and requires that dietary counseling be tailored to the needs of the individual depending on which stage they are in rather than a “1 size fits all” approach. One such model is the Transtheoretical Model4,5 (Fig 1). During the course of consultation with patients, clinicians will be able to identify where their patients are in the process of change—whether they are open to the idea of change or are resistant to change.
tailoring dietary advice
Individuals receive cues to change their dietary behavior from a variety of sources. It is common sense that individually tailored advice is more effective than mass messages. This has been acknowledged in recent public health guidance on smoking cessation and physical activity in the United Kingdom, which encourages tailoring information to the individual patients’ needs by means of “opportunistic advice, discussion, negotiation, or encouragement.”6,7
An individual’s eating behavior is the result of a complex amalgamation of and interrelationship between social, cultural, and biological factors. Attempting to change dietary behavior is, therefore, a difficult task, as it reflects both lifestyle and self-identity.8 One suggested method for facilitating this complex behavior change is through the use of motivational interviewing (MI). MI involves collaboration between the dental health professional and patient: the dental health professional elicits the motivation to change from the patient through drawing on their own perceptions, goals, and values, while the responsibility for change remains with the patient.10 The focus of the motivational interview is to examine and resolve ambivalence, defined as a key obstacle to change, in a patient-centered and directive manner.9
MI has been linked with the transtheoretical model, which assists by “providing a framework for understanding the change process itself,” while MI provides “a means of facilitating this change.”11 The combination of MI skills with the transtheoretical model is ideally suited to the promotion of dietary change.3 Dietary counseling that tailors advice to the patient’s readiness to change should ensure closer agreement between the patient and the dental health professional, cause less resistance, and improve the effectiveness of the dietary intervention.12 Use of MI for dietary change may help patients come to terms with a chronic condition and explore their ambivalence toward the burden of change and the loss of a favorite less healthy food.13
Using MI may require some adjustments for the dental health professional from traditional prescriptive methods of patient education to becoming more facilitative and collaborative.13 The most limiting factor of using MI in a dental practice setting is time; therefore, a briefer format of MI may be required13 when there may not be sufficient time to fully explore the patient’s ambivalence.
Rollnick et al14 developed brief MI techniques for use in the health care setting to enable the practitioner to select a strategy to match the patient’s readiness to change. The menu (outlined in Table 1) is ordered according to readiness to change, with latter strategies aimed at patients who are more ready to change. The earlier strategies are designed to be used with most patients. Dental health professionals who use the tool must be flexible in their approach and avoid going too far down the menu. They should be aiming to have a collaborative conversation about changing dietary behavior.
Applying the MI menu to dietary change
By asking open-ended questions, rather than closed questions that elicit yes/no answers, the dental health professional can discuss the patients current dietary patterns and probe further to put this into context in relation to their patients’ oral (and/or general) health (points 1 and 2).
If you ask permission to talk about a topic, patients will not feel it has been forced on them. For example: Is it ok with you if we talk about what you eat? Talking through a “typical day” helps bring the eating behavior into context for the dental health professional and also helps to build rapport with the patient (point 3).
Working through the pros and cons of changing eating behavior helps patients to explore their ambivalence (point 4). This illustrates the importance of changing the dietary behavior to the individual.15 In relation to changing their diet, individuals may weigh the importance of making changes, which may result in removing familiar foods which they enjoy.
In routine consultations, dentists and other health practitioners give information to patients. The MI technique encourages health practitioners to give information in a sensitive manner and encourages that permission be asked before information is provided (point 5). Practictioners should try to avoid falling into an advice-giving trap. Rollnick et al15 describe the 2 techniques that are usually included in advice-giving: (1) providing information, which tends to use tactics of fear induction, and (2) using persuasion, explaining why they should do what the practictioner tells them to do. Neither of these techniques works well to induce changes in dietary behavior.
Listening to the concerns of the patient involves reflective listening and summarizing (point 6). The consultation is an active process involving both clinician and patient. The goal is to have a collaborative conversation about changing dietary behavior. The empathetic and reflective listening process is more than just listening; it is an active listening process where the clinician replies and reflects on what the patient has said. Through this technique, the clinician aims to clarify the thoughts and feelings the patient is trying to convey by making statements of understanding.
The dental health professional can help with the decision-making process by presenting a set of options for bringing about dietary changes, describing strategies that have worked for other people, and providing information in a neutral manner (point 7). Ultimately, patients should choose the dietary goals themselves. These should be as specific as possible. After deciding on a specific goal, eg, to increase fruit consumption, patients can set a more specific plan, taking into account details such as where, how often, and the support available to them.
MI holds substantial promise for changing health behavior. It is patient-centered, can be tailored to the patient’s degree of readiness to change, and is an effective means for working with patients who are ambivalent or not ready for change. It may assist clinicians in helping patients to change their dietary behaviors.