Assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults.

Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) i
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
[Intervention Review]
Interventions to enhance adherence to dietary advice for
preventing and managing chronic diseases in adults
Sophie Desroches1,2, Annie Lapointe1,2, Stéphane Ratté1, Karine Gravel2, France Légaré3, Stéphane Turcotte1
1Centre de recherche du Centre hospitalier universitaire de Québec (CHUQ), St-François d’Assise Hôpital, Québec, Canada.
2Département des sciences des aliments et de nutrition, Université Laval, Québec, Canada. 3Département de médecine familiale et
d’urgence, Université Laval, Québec, Canada
Contact address: Sophie Desroches, Centre de recherche du Centre hospitalier universitaire de Québec (CHUQ), St-François d’Assise
Hôpital, 10 Rue de l’Espinay, Office D6-740, Québec, Québec, G1L 3L5, Canada. sophie.desroches@fsaa.ulaval.ca.
Editorial group: Cochrane Consumers and Communication Group.
Publication status and date: New, published in Issue 2, 2013.
Citation: Desroches S, Lapointe A, Ratté S, Gravel K, Légaré F, Turcotte S. Interventions to enhance adherence to dietary advice
for preventing and managing chronic diseases in adults. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD008722.
DOI: 10.1002/14651858.CD008722.pub2.
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
A B S T R A C T
Background
It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary
advice is a critical component in preventing and managing chronic diseases.
Objectives
To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults.
Search methods
We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE
(Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions.We also reviewed: a) recent years of relevant
conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies
of included studies.
Selection criteria
We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and
managing chronic diseases in adults. Studies were eligible if the primary outcome was the client’s adherence to dietary advice. We
defined ’client’ as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice.
Data collection and analysis
Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using
a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in
judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect
to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and followup,
we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results
in a narrative table using vote counting for each category of intervention.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 1
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Main results
We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention
group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control
group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data
and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet
adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including
multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/
usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies
reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term
also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session,
reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference
favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied
widely.
Authors’ conclusions
There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify
the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.
P L A I N L A N G U A G E S U M M A R Y
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults
Chronic diseases are the leading cause of mortality worldwide. Although the adoption of a healthy diet is recognized as an important
component for their prevention andmanagement, many individuals at risk of or having chronic diseases do not adhere to recommended
dietary advice. The methods used to facilitate changes in dietary habits through dietary advice (defined in this review as ’interventions’)
could improve adherence of clients to dietary advice. Therefore, we reviewed trials of interventions aiming to enhance adherence to
dietary advice for preventing and managing chronic diseases in adults.
We identified 38 studies involving 9445 participants examining several types of interventions for enhancing adherence to dietary
advice for preventing and managing many chronic diseases. The main chronic diseases involved were cardiovascular diseases, diabetes,
hypertension, and renal diseases. Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video,
contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions
also showed no difference in some diet adherence outcomes compared to a control/usual care group making the results inconclusive
about the most effective intervention to enhance dietary advice. Interestingly, all studies including clients with renal diseases reported
at least one diet adherence outcome showing a statistically significant difference favouring the intervention group, no matter which
intervention was provided. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to
the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions
such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome
showing a statistically significant difference favouring the intervention group. Finally, interventions were generally of short duration,
studies used different methods for measuring adherence and the quality of the studies was generally low.
B A C K G R O U N D
Description of the condition
Chronic diseases are defined as diseases of long duration that have
generally a slow progression (WHO 2008). The most common
chronic diseases include diabetes, cardiovascular diseases (CVD),
cancers, asthma, chronic obstructive pulmonary diseases (COPD),
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 2
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
arthritis, obesity and renal failure. Considering that chronic diseases
are the leading cause of death and disability and account for
60% of all deaths worldwide (WHO 2008), the Department of
Chronic Disease and Health Promotion of theWorld Health Organization
(WHO) emphasizes the importance of preventing and
managing chronic diseases and their risk factors (WHO 2010).
Some health conditions have been found to be risk factors, for
example, patients with the metabolic syndrome have an increased
risk of developing CVD (Mottillo 2010). Similarly, women with
a previous history of gestational diabetes have an increased risk of
developing type II diabetes (Bellamy 2009). These risk factorsmay
be targeted in interventions aiming to prevent chronic diseases.
Evidence from epidemiologic, experimental and clinical studies
has demonstrated a strong relationship between dietary patterns or
nutrient intakes, and prevention and management of chronic diseases
including diabetes (Champagne 2009), CVD (Lavie 2009),
and obesity (Kennedy 2004). Several authoritative health agencies
have recommended the adoption of a healthy diet as the cornerstone
in preventing and/or managing chronic diseases such
as CVD (Lichtenstein 2006), diabetes (Bantle 2008) and cancer
(Kushi 2006). For example, lifestyle interventions including dietary
changes were shown to reduce the incidence of diabetes by
58%compared to a control group in individuals at high risk in two
large randomized controlled trials (RCTs): the Finnish Diabetes
Prevention study (Lindstrom 2003) and the Diabetes Prevention
Program (Knowler 2002). In line with this, dietitians and other
health professionals provide people with dietary advice designed
to improve their nutritional intake (Baldwin 2011).
The concept of ’adherence’ recognizes the patient’s right to choose
whether or not to follow advice, and implies a patient’s active participation
in the treatment regimen (Cohen 2009). For chronic
disease management including medication and lifestyle changes,
non-adherence rates are estimated to be between 50% and 80%
(WHO 2003). Thus, poor adherence can be a serious threat to
patients’ health and wellbeing (DiMatteo 2002), and also carries
an economic burden (DiMatteo 2004a). Adherence is particularly
important in the context of chronic diseases requiring longterm
therapy and a number of permanent rather than temporary
changes in lifestyle behaviours, such as diet, physical activity and
smoking (WHO 2003). The extent to which risk-reduction interventions
proved to be as effective in research settings as in individuals’
real-life settings depends on the patient’s adherence to
treatment advice. In that regard, results from an RCT assessing
adherence to and effectiveness of four popular diets (Atkins, Zone,
Weight Watchers, and Ornish) revealed that level of adherence
to dietary advice, rather than the type of diet, was the key determinant
of greater weight loss and CVD risk factor reductions
(Dansinger 2005). Whether the number of intervention goals that
an individual has to reach influences adherence was also addressed
in a secondary analysis of the PREMIER study (Young 2009). In
this RCT that tested the effects of two multicomponent lifestyle
interventions on blood pressure control, the authors reported that
individuals with the most physical activity and dietary behaviour
goals to achieve reached the most goals (Young 2009).
Measurement of adherence to prescribed dietary advice typically
involves: 1) assessment ofwhat the client eats through self-reported
methods (e.g. 24-hour recall, food records, food frequency questionnaires,
diet history); and 2) determination of the degree to
which the diet approximates the recommended dietary plan (e.g.
difference between clients’ recommendedmacronutrient goals and
their self-reported intake). Although sparsely used, more objective
measures of adherence to diets also exist (e.g. 24-hour urinary
sodium excretion to assess adherence to a low sodium diet (Chung
2008)). However, there is no gold standard for the accurate determination
of dietary intake. Self-report of energy intake is a characteristic
inherent to nutrition-related topics and is found to be underestimated
compared to objective measures such as resting energy
expenditure assessed by indirect calorimetry (Asbeck 2002).
Underreporting energy intake has been observed more frequently
in women versus men, (Johnson 1994), in older versus young
(Huang 2005), and in obese versus normal weight individuals
(Briefel 1997). Although self-report measures are often regarded
as susceptible to bias (e.g. over reliance on memory; report error
related tomeal composition or portion sizes; daily dietary variability;
social desirability) (Kumanyika 2000; Wilson 2005) they are
a direct, simple and inexpensive method (DiMatteo 2004b), and
are readily available for use in practice. Self-reportmeasures can be
improved and validated by using multiple measures of adherence
and controlling statistically for bias or by using constructs such as
body weight, blood pressure or plasma cholesterol concentrations
(Hebert 2001; DiMatteo 2004b).
Description of the intervention
Adherence to dietary advice has been shown to vary according to
gender (Chung 2006), socio-economic status (Reid 1984) and ethnicity
(Natarajan 2009).Moreover, numerous barriers to client adherence
in health care have been identified. Among themare complexity
of treatment plan, and clients’ knowledge of disease and
understanding of the importance of treatment in its control and
in preventing adverse outcomes (Makaryus 2005 ;Harmon 2006;
Robinson 2008). According to a WHO report, “interventions for
removing barriers to adherence must become a central component
of efforts to improve population health worldwide” (WHO
2003). Although non-adherence is often attributed to clients who
are viewed as “non cooperative”, “non compliant” and “unable to
follow instructions” (Kapur 2008), it is increasingly recognized
that health professionals may help their clients overcome barriers
to adherence (Harmon 2006) by improving how they approach
their clients’ problems, how they provide advice, and how they
involve their clients in treatment decision making. Although there
is a wide diversity of interventions for enhancing adherence to dietary
advice, their underlying aim is to prompt change to facilitate
the adoption of recommended dietary behaviours.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 3
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How the intervention might work
Behaviour change theories have proved useful for explaining
health-related behaviours, including dietary behaviours. They attempt
to identify the determinants that will contribute to predict
the adoption of a specific behaviour, and which should be taken
into account when developing a behaviour change intervention,
such as a method for providing dietary advice. Several models or
theories to predict behaviour change can be used in health-related
interventions, such as the Health Belief Model (Rosenstock
1974), the Theory of Planned Behaviour (Ajzen 1991), the Theory
of Reasoned Action (Fishbein 1981) and the Social Cognitive
Theory (Bandura 1986). More recently, Michie 2011 proposed
a framework, the COM-B system, which includes three principal
interrelated components of the determination of a behaviour: 1)
the motivation (the direct brain process leading to a behaviour),
2) the capability (the individual’s psychological and physical capacity
to engage a behaviour) and 3) the opportunity (the factors
that lie outside the individual that make the behaviour possible or
not) (Michie 2011).The authors also developed a system for characterizing
behaviour change interventions and their components
in order to facilitate the identification of the effective behaviour
change interventions and the implementation of evidence-based
practice in this area. According to this system, behaviour change
interventions can be classified as nine intervention functions: education,
persuasion, incentivisation, coercion, training, restriction,
environmental restructuring, modelling and enablement (Michie
2011). These theories or models focus on different determinants
or combinations of determinants of the behaviours which could
be helpful for developing interventions for enhancing adherence
to dietary advice.
Why it is important to do this review
As greater adherence to dietary advice is a critical component in
preventing and managing chronic diseases, research is needed to
identify the characteristics of interventions that will result in a better
agreement between health professionals’ evidence-based dietary
advice, and their clients’ eating patterns. Despite growing recognition
that non-adherence to dietary advice is a barrier to getting
new nutrition knowledge into practice, previous knowledge syntheses
have provided decision makers and knowledge users with
little practical guidance on the development of useable interventions
for enhancing adherence to dietary advice. Studies have reported
on interventions designed to enhance adherence to dietary
advice by overcoming barriers to adherence. Although some studies
have reported positive effects of interventions to enhance adherence
to dietary advice, no systematic review specifically assesses
dietary interventions that lead to sustained dietary changes or that
refer to a wide array of chronic diseases. Haynes 2008 summarized
the results of RCTs of interventions to help clients adhere to prescriptions
for medications for medical problems, and excluded interventions
targeting dietary advice. Bosch-Capblanch 2007 systematically
reviewed the effects of contracts between clients and
health professionals for improving clients’ adherence to treatment,
prevention and health promotion activities. Although this review
is relevant to our review, it reported only the effect of contracts
(as opposed to other interventions), and was not specific to dietary
advice. Several non-Cochrane reviews may overlap with our
review, but these are not systematic (Brownell 1995b; Brownell
1995a; Burke 1997; Newell 2000; Fappa 2008) and/or are related
to only one health condition and not specifically targeting dietary
advice (Burke 1997; Newell 2000; Fappa 2008).
This review will improve the knowledge base for adherence to
dietary advice; a topic of immense importance for dietetics practice
that will also be relevant to clients, and other health professionals.
O B J E C T I V E S
To assess the effects of interventions for enhancing adherence to
dietary advice for preventing and managing chronic diseases in
adults.
M E T H O D S
Criteria for considering studies for this review
Types of studies
Randomized controlled trials (RCTs) including cluster RCTs. Because
interventions for enhancing adherence to dietary advice aim
to initiate dietary changes, a cross-over design in which each client
received all interventions could induce a carry-over effect. Therefore,
we excluded studies including a cross-over design.
Types of participants
Clients, aged 18 years and over, in real-life settings. We define
’client’ as an adult participating in a chronic disease prevention
or chronic disease management study involving dietary advice.
We included clients who had a diet related-chronic disease (e.g.
obesity, cardiovascular disease, renal failure, hypertension) or at
least one risk factor for a chronic disease (e.g. overweight, hyperlipidaemia).
We included family or non-family caregivers such as
wife/husband or individual living with the client and involved in
meal planning and preparation. We also included studies involving
health professionals delivering dietary advice.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 4
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Types of interventions
We included studies assessing the effects of a single intervention or
multiple interventions involving chronic disease prevention and
management, on adherence to dietary advice. ’Intervention’ was
defined as the method used to facilitate changes in dietary habits
through dietary advice. To structure the presentation of results, we
grouped interventions according to the intervention functions of
the behaviour change wheel developed by Michie and colleagues
(Michie 2011). Therefore, we classified interventions to enhance
adherence to dietary advice as:
• Education (increasing knowledge or understanding);
• Persuasion (using communication to induce positive or
negative feelings or stimulate action);
• Incentivisation (creating expectation of reward);
• Coercion (creating expectation of punishment or cost);
• Training (imparting skills);
• Restriction (using rules to reduce the opportunity to engage
in the target behaviour);
• Environmental restructuring (changing the physical or
social context);
• Modelling (providing an example for people to aspire to or
imitate) ;
• Enablement (increasing means/reducing barriers to increase
capability or opportunity);
• Multiple (combination of two or more different
interventions).
We included studies making the following comparisons:
• Single intervention for enhancing adherence to dietary
advice versus no intervention (control) or a reference standard of
care (usual care);
• Single intervention for enhancing adherence to dietary
advice versus single or multiple interventions with a similar
purpose (to enhance adherence to dietary advice);
• Multiple interventions for enhancing adherence to dietary
advice versus no intervention (control) or a reference standard of
care (usual care);
• Multiple interventions for enhancing adherence to dietary
advice versus single or multiple interventions for enhancing
adherence to dietary advice.
The term ’reference standard of care’ refers to the usual dietary
intervention performed to address a specific health condition. For
example, in Amato 1990 two approaches were used with patients
who were severely obese using the same dietary advice: 1) weight
loss advice versus 2) weight loss advice combined with psychotherapy.
The approach with weight loss advice was the reference standard
of care while the approach with weight loss advice combined
with psychotherapy was the intervention for enhancing adherence
to dietary advice. Furthermore, only studies comparing interventions
with the same dietary advice component (e.g. increase consumption
of fruits and vegetables, decrease fat intake) but differing
in terms of themethod for changing dietary habits through dietary
advice (e.g. education (counselling and follow-up with health professional,
educational tools)) were included. We excluded studies
assessing adherence to dietary advice for which interventions were
not a method for facilitating changes in dietary habits through
dietary advice (e.g. medication for weight loss, exercise, etc.).
We excluded studies that aimed primarily to evaluate the effects of
an experimental diet or a food plan on health outcomes, and for
which adherence was monitored as a secondary outcome to justify,
for example, the validity of the results, as these interventions were
not designed for enhancing adherence to dietary advice. We only
included studies including food-based dietary advice and representing
real-life conditions. Therefore, we excluded studies involving
the provision of meals, food items or dietary supplements (e.g.
vitamin, mineral, omega-3 fatty acid).
Types of outcome measures
Primary outcomes
• Client adherence to dietary advice (e.g. biochemical
measures within acceptable limits, mean dietary intake,
proportion of clients achieving the dietary advice). We included
studies reporting adherence to dietary advice as a primary
outcome, namely those clearly mentioning a measurement of
diet adherence in the title or the objective of the study and/or
those reporting the proportion of patients adhering to dietary
advice. We excluded studies reporting mean dietary intake
without specifically assessing adherence to dietary advice.
Secondary outcomes
• Process measures: e.g. attendance at or participation in
individual counselling or group sessions, number of completed
food records returned to research coordinators, client or family
or non-family caregivers’ satisfaction with the dietary or
counselling approaches, health professionals’ skills in performing
the experimental interventions or their satisfaction with the
counselling approach.
• Client-based health or behaviour outcomes: e.g. blood
pressure; plasma cholesterol concentration; plasma glucose
concentration; body weight; relief of symptoms; smoking;
physical activity; blood glucose monitoring.
• Organisational outcomes: e.g. cost; time; resources required
by client, family or non-family caregivers, or healthcare
professionals.
• Harms or secondary effects: e.g. confusion regarding new
eating patterns; feelings of lack of confidence or skills in
preparing meals; unhappiness at loss of traditional meals.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 5
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Search methods for identification of studies
Electronic searches
We conducted a systematic search, using 29 September 2010 as
the cut-off date, in the following electronic databases:
• The Cochrane Library, issue 9 2010 (via Wiley);
• PubMed;
• EMBASE (Embase.com);
• CINAHL (Ebsco);
• PsycINFO (PsycNet).
We present detailed search strategies in Appendix 1; Appendix 2;
Appendix 3; Appendix 4; Appendix 5. There were no language
restrictions and all databases were searched from their start date.
Searching other resources
We conducted additional searches for unpublished studies through
grey literature:
• Recent years of relevant conference, symposium and
colloquium proceedings and abstracts:
• ◦ 2009-10 Scientific sessions of the American Diabetes
Association;
◦ 2009-10 Scientific sessions of the American Heart
Association;
◦ 2009-10 Food and Nutrition Conference and Expo of
the American Dietetic Association;
◦ 2010 Canadian Diabetes Association/Canadian
Society of Endocrinology and Metabolism Professional
Conference and Annual Meeting;
◦ 2009 International Diabetes Federation World
Diabetes Congress North America;
◦ 2009-10 Dietitians of Canada National Conference;
◦ 2009-10 Obesity Society Annual Scientific Meeting;
◦ 2009-10 Experimental Biology Meeting;
◦ 2009-10 Canadian Nutrition Society;
• Web-based registries of clinical trials (US National
Institutes of Health, The National Library of Medicine, Current
Controlled Trials);
• Bibliographies of included studies;
• Contact with experts in the field to request details of any
other known studies.
Data collection and analysis
Selection of studies
Two review authors independently assessed the eligibility of papers
identified by the search strategy. All titles and abstracts
were screened according to pre-established inclusion criteria (see
Criteria for considering studies for this review). We retrieved full
text copies of papers judged to be potentially relevant to the review.
Disagreements were resolved by discussion between the two
review authors, and when consensus was not reached, with a third
review author.We attempted to contact authors to obtain further
details of papers containing insufficient information tomake a decision
about eligibility. If no response was provided, we sent up to
two reminders and, when possible, also contacted one co-author.
We contacted 81 authors of whom 67 provided a response.
Data extraction and management
Two review authors performed the data extraction independently
fromall included studies using amodified version of theCochrane
Consumers and Communication Review Group data extraction
template (CCCRG 2010). In addition to the standard form derived
from the data extraction template of the Cochrane Consumers
and Communication Review Group, other relevant information
was extracted including:
• Food-based dietary advice;
• Rationale underlying the dietary advice (e.g. clinical
practice guidelines, other evidence-based sources);
• Adherence assessment method (proportion of clients
achieving the dietary advice, biochemical measures);
• Description of the intervention (eg. education, persuasion,
training).
Any discrepancies in judgement were resolved by discussion and
consensus, or with a third review author. Where information was
missing, we contacted the corresponding author. If no answer was
provided, we sent up to two reminders and, when possible, also
contacted one co-author. We contacted 38 authors of included
studies, of whom 22 provided a response.
Assessment of risk of bias in included studies
Two review authors assessed and reported on the risk of bias of
included RCTs in terms of the following individual elements that
affect risk of bias:
• Random sequence generation;
• Allocation concealment;
• Blinding – clients, providers and outcome assessors;
• Incomplete outcome data;
• Selective reporting;
• Other bias.
Each of the risk of bias items was assessed as ’low risk of bias’,
’high risk of bias’ and ’unclear risk’ based on the study reports
and/or additional information provided by the study authors. Any
discrepancies in judgement were resolved by discussion and consensus,
or with a third review author.
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Measures of treatment effect
The table Characteristics of included studies includes descriptions
of study design, setting, country, chronic disease, type of participants
(age, sex, ethnicity), sample size, intervention(s) and/or control/
usual care, measurement of diet adherence, dietary advice,
drop-out rate and providers. Sample size is presented as the number
of randomized clients, or when the authors did not report it, as
the number of completers. Drop-out rate is presented as reported
or as calculated when the authors did not report it.
Since the included studies addressed a wide range of interventions,
measures of diet adherence, dietary advice, nature of chronic diseases,
and duration of interventions and follow-up, it was impossible
to perform meta-analyses. For this reason, we could not apply
all the methods outlined in the protocol (Desroches 2010) but
present these in Appendix 6 for application in future updates of
the review. To facilitate the presentation of results, two authors independently
classified included studies according to the function
of the intervention (Michie 2011). Any discrepancies in judgement
were resolved by discussion and consensus, or with a third
review author. The method(s) for facilitating changes in dietary
habits through dietary advice used in the intervention group and
differing from the method(s) used in the comparative group (control,
usual care or other intervention group) was (were) defined
as the intervention and was (were) classified according to different
categories of interventions (education, persuasion, incentivisation,
coercion, training, restriction, environmental restructuring,
modelling, enablement and multiple). Representing each category
of interventions, eight additional tables (Additional tables)
summarize narratively the number of studies and participants per
intervention, the effect on diet adherence and the quality of evidence
(GRADE) (Higgins 2011). In case of discrepancies between
the results provided by the authors and the risk ratio (RR)
or the standardized mean difference (SMD) calculated using ReviewManager
5 (’RevMan’) software (RevMan 2012), we selected
the results provided by RevMan to complete the Additional tables.
Some studies assessed and therefore reported multiple diet
adherence outcomes (e.g. adherence to fiber intake and adherence
to cholesterol-restricted diet) and/or evaluated diet adherence
outcome(s) at different times (e.g. one month, three months,
six months). Consequently, we used vote counting, that is we reported
the number of diet adherence outcomes favouring the intervention
out of the total number of diet adherence outcomes
reported, regardless of the statistical significance or size of their
results (Higgins 2011), to assess studies that reported diet adherence
outcomes between an intervention group and a control/usual
care group. Studies are described in more than one category of intervention
if they investigated more than one intervention (Baraz
2010; Cummings 1981; Hsueh 2007; Jones 1986; Kendall 1987;
Logan 2010; Mahler 1999; McCulloch 1983). Only studies that
compared an intervention with a control/usual care group were
included in these Additional tables.
We used RevMan to create forest plots when diet adherence outcomes
provided raw and complete data (means and standard deviations
for continuous data, and number of events and number of
total observations for dichotomous data). We analyzed dichotomous
data by determining the RR and 95% confidence intervals.
We analyzed continuous data by determining the SMD of
the intervention and the control groups in each study with 95%
confidence intervals. Only studies comparing a single or multiple
intervention group with a control/usual care group were included
in forest plots. We used mean differences between prepost
intervention to calculate SMD. When these data were not
known, and that baseline data were available for the two groups,
we corrected the standard effect size by calculating the difference
between pre- and post-intervention values. The pooled estimates
standard deviation was used to calculate the standard deviation of
this difference. When no baseline data were reported, groups were
considered to be similar before the intervention. Outcomes with
data including covariate-adjusted means or imputed means were
not analysed with forest plots. For these studies, we presented the
qualitative data as reported by the study authors. Some elevated
SMDs could represent a high diet adherence (e.g. fruit, vegetable
and fiber intakes) whereas some elevated SMDs could represent a
low diet adherence (e.g. energy, fat and sodium intakes). Therefore,
to correct for difference in the direction of the scale in forest
plots, means of the intervention and the control groups were
multiplied by -1 for outcomes where elevated SMD represented a
high diet adherence (e.g. fruit, vegetable and fiber intakes). When
authors did not report statistical analyses, we used data to calculate
the SMD or the RR in RevMan in order to compare differences
in outcomes between groups.
Assessment of heterogeneity
We did not explore heterogeneity due to the wide range of interventions,
measures of diet adherence, dietary advice, nature of
chronic diseases, and duration of interventions and follow-up addressed
in included studies.
Consumer participation
The Cochrane Consumers and Communication Review Group’s
editorial process for the protocol (Desroches 2010) and the review
involved two anonymous consumer referees. We also sought additional
feedback throughout the review process from representatives
of the Dietitians of Canada to ensure that important issues
for health professionals were addressed.
R E S U L T S
Description of studies
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 7
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Results of the search
From the searches, we identified 5183 potentially-relevant publications
after duplicates were removed. From these, we excluded
4786 publications after examining the titles and abstracts, and we
retrieved 398 full-texts of potentially-relevant publications. From
these, 42 publications (describing 38 unique studies) met our inclusion
criteria and were considered as eligible.We classified a further
5 publications (describing 6 studies) as ongoing studies (see
Characteristics of ongoing studies), and 20 publications as studies
awaiting classification (See Characteristics of studies awaiting
classification) (see Figure 1, Study Flow Diagram).
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 8
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Figure 1. Study flow diagram.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 9
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Included studies
Three included studies were described in more than one publication.
First, Jiang’s PhD thesis was published later in an electronic
journal (Jiang 2004). Similarly, Chow’s PhD thesis was published
later in an electronic journal (Wong 2010). Miller 1988, Miller
1989 and Miller 1990 (Miller 1988) all described the same study
and reported results for diet adherence at 30 and 60 days, 1 year
and 2 years, respectively. We refer to this study as Miller 1988.
Therefore we included 38 studies reported in 42 publications (See
Characteristics of included studies).
All included studies were RCTs. Only one of them used cluster
randomisation (Wood 2008).
Location, setting and duration
Studies were conducted in the following countries:
Country Number of studies Studies
United States of America 14 Aldarondo 1999; Beasley 2008; Becker 1998; Cummings 1981;
Gans 1994;Gill 2010;Hsueh 2007;Hyman 2007;Kendall 1987;
Mahler 1999; Micco 2007; Miller 1988; Racelis 1998; Scisney-
Matlock 2006
United Kingdom 7 Bennett 1986; French 2008; Grace 1996; Jones 1986; Logan
2010; McCulloch 1983; Morey 2008
China 5 Chen 2006; Chiu 2010; Jiang 2004; Wong 2010; Zhao 2004
Canada 4 Arcand 2005; Conrad 2000; Gucciardi 2007; Ryan 2002
Brazil 1 Assuncao 2010
Iran 1 Baraz 2010
The Netherlands 1 Blanson 2009
Finland 1 Laitinen 1993
Norway 1 Meland 1994
South Africa 1 Stewart 2005
Taiwan 1 Tsay 2003
Multiple (France, Italy, Poland, Spain, Sweden,
United Kingdom, Denmark and the
Netherlands)
1 Wood 2008
All included studieswere directed towards clients and none of them
was directed towards family or non-family caregivers or health
professionals.
An outpatient setting was reported in the majority of the included
studies (n = 31). Four studies were carried out in a research center
setting (Beasley 2008; Blanson 2009; Hsueh 2007; Micco 2007)
while one study (Gans 1994) included two settings (workplace and
community). In two studies, the setting could not be identified
(Aldarondo 1999; Bennett 1986).
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 10
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Nineteen studies evaluated diet adherence to dietary advice over
a period of less than 6 months (Aldarondo 1999; Arcand 2005;
Baraz 2010; Beasley 2008; Bennett 1986; Blanson 2009; Chen
2006; Chiu 2010; Cummings 1981; Gans 1994; Gill 2010; Grace
1996; Gucciardi 2007; Jones 1986; Mahler 1999; Meland 1994;
Scisney-Matlock 2006;Wong 2010; Zhao 2004), nine studies had
a duration between 6 and 12 months (Assuncao 2010; Conrad
2000; Hsueh 2007; Jiang 2004; Kendall 1987; McCulloch 1983;
Ryan 2002; Stewart 2005; Tsay 2003), while only 10 studies evaluated
diet adherence to dietary advice over a 12-month period or
more (Becker 1998; French 2008; Hyman 2007; Laitinen 1993;
Logan 2010;Micco 2007;Miller 1988;Morey 2008;Racelis 1998;
Wood 2008).
Clients
The 38 studies included in this review involved 9445 clients. The
range in the number of clients in each study varied from7 to 5405
(median = 83). Only 13 of the 38 studies provided a power calculation
(Aldarondo 1999; Assuncao 2010; Beasley 2008; Chiu
2010; French 2008; Hyman 2007; Jiang 2004; Meland 1994;
Stewart 2005; Tsay 2003; Wong 2010; Wood 2008; Zhao 2004)
and among them, 10 studies recruited the number of clients according
to their power analysis (Aldarondo 1999; Assuncao 2010;
Beasley 2008; French 2008; Jiang 2004; Meland 1994; Stewart
2005; Tsay 2003; Wong 2010; Zhao 2004).
Prevention of chronic diseases
Five studies included clients receiving dietary advice for the prevention
of chronic diseases, such as clients with a high risk of CVD
(clients having dyslipidaemia (Gans 1994; Grace 1996), siblings
of individuals with coronary heart diseases (Becker 1998)) and
overweight clients (Blanson 2009; Jones 1986).
Management of chronic diseases
Twenty-seven included studies addressed dietary advice for chronic
disease management. Eight studies included clients receiving dietary
advice for the management of CVD (heart failure (Arcand
2005), coronary heart disease (Logan 2010; Zhao 2004), coronary
artery disease (Conrad 2000;Mahler 1999), peripheral artery
disease (Racelis 1998), angina pectoris and myocardial infarction
(Jiang 2004; Miller 1988)); six studies involved the management
of diabetes (French 2008; Gucciardi 2007; Kendall 1987;
Laitinen 1993; McCulloch 1983; Ryan 2002); five studies involved
the management of hypertension (Chiu 2010; Hyman
2007; Meland 1994; Scisney-Matlock 2006; Stewart 2005); six
studies addressed the management of renal failure (Baraz 2010;
Chen 2006; Cummings 1981; Morey 2008; Tsay 2003; Wong
2010); one study addressed themanagement of obesity (Aldarondo
1999): and one study addressed themanagement of irritable bowel
syndrome (Hsueh 2007).
Prevention and management of chronic diseases
Six studies included clients receiving dietary advice for both the
prevention and the management of chronic diseases. One study
was conducted with clients with coronary heart disease and clients
with a high risk of developing CVD(Wood 2008). The remaining
five studies included overweight and obese clients (Assuncao 2010;
Beasley 2008; Bennett 1986; Gill 2010; Micco 2007).
Interventions
Included studies assessed interventions in the following categories:
Education
Nine studies offered nutrition counselling and follow-up with a
health professional through telephone follow-up (Chiu 2010;
Cummings 1981; Racelis 1998; Stewart 2005), group sessions
(Gill 2010; Jones 1986) or individual sessions with a dietitian
(Jones 1986; Micco 2007) or a nurse (Hsueh 2007). Moreover,
four studies used educational tools to provide dietary advice such
as video (Baraz 2010; Mahler 1999;McCulloch 1983) or booklet
(Kendall 1987).
Persuasion
Two studies used reminders (Gans 1994; Ryan 2002).
Incentivisation
One study used contracts with rewards (Cummings 1981).
Training
Three studies used feedback (Beasley 2008; French 2008;Meland
1994).
Restriction
Only one study compared an immediate versus an incremental
reduction of fat intake (Conrad 2000).
Modelling
Seven studies used nutritional tools such as menus, exchange list
and portion size examples in order to enhance diet adherence (
Assuncao 2010; Chen 2006; Grace 1996; Kendall 1987; Logan
2010; McCulloch 1983; Scisney-Matlock 2006).
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Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Enablement
Three studies used one or more behaviour change techniques, including
barrier identification/problem solving (Aldarondo 1999;
Bennett 1986; Logan 2010), goal setting (Logan 2010), self-talk
(defined as use of self-instruction and self-encouragement to support
action by AbrahamandMichie (Abraham2008)) (Aldarondo
1999; Bennett 1986) and teaching to use prompts/cues (defined
as teaching the person to identify environmental cues that can be
used to remind them to perform a dietary behaviour by Abraham
and Michie (Abraham 2008)) (Bennett 1986).
Multiple
This category includes 18 studies using a combination of two or
more different interventions (Arcand 2005; Baraz 2010; Becker
1998; Blanson 2009; Cummings 1981; Gucciardi 2007; Hsueh
2007; Hyman 2007; Jiang 2004; Jones 1986; Laitinen 1993;
Mahler 1999;Miller 1988; Morey 2008; Tsay 2003;Wong 2010;
Wood 2008; Zhao 2004).
Outcomes
Twenty-eight studies compared two groups (Aldarondo 1999;
Arcand 2005; Assuncao 2010; Baraz 2010; Beasley 2008; Becker
1998; Blanson 2009; Chen 2006; Chiu 2010; Conrad 2000; Gill
2010; Grace 1996; Gucciardi 2007; Hsueh 2007; Kendall 1987;
Jiang 2004; Laitinen 1993; Logan 2010; Meland 1994; Micco
2007; Miller 1988; Morey 2008; Racelis 1998; Scisney-Matlock
2006; Stewart 2005;Tsay 2003;Wong 2010;Zhao 2004), six studies
compared three groups (Bennett 1986; French 2008; Hyman
2007;Mahler 1999;McCulloch 1983; Ryan 2002) and four studies
compared four groups (Cummings 1981; Gans 1994; Jones
1986; Wood 2008). Twenty-five studies assessed a single diet
adherence outcome (Arcand 2005; Beasley 2008; Becker 1998;
Bennett 1986; Blanson 2009; Chen 2006; Chiu 2010; Conrad
2000;Gans 1994;Gill 2010;Gucciardi 2007;Hyman 2007; Jiang
2004; Jones 1986; Logan 2010; Mahler 1999; McCulloch 1983;
Meland 1994; Micco 2007; Miller 1988; Morey 2008; Racelis
1998; Scisney-Matlock 2006; Tsay 2003; Zhao 2004) while 13
studies assessed multiple diet adherence outcomes (Aldarondo
1999; Assuncao 2010; Baraz 2010; Cummings 1981; French
2008; Grace 1996; Hsueh 2007; Kendall 1987; Laitinen 1993;
Ryan 2002; Stewart 2005; Wong 2010; Wood 2008). Twenty
studies assessed diet adherence outcome(s) once (Aldarondo 1999;
Arcand 2005; Assuncao 2010; Baraz 2010; Beasley 2008; Becker
1998; Bennett 1986; Blanson 2009; Chen 2006; Chiu 2010;
Conrad 2000; French 2008; Gans 1994; Gill 2010; Grace 1996;
Gucciardi 2007; Jones 1986; McCulloch 1983; Racelis 1998;
Wood 2008), 13 studies assessed diet adherence outcome (s)
twice (Cummings 1981; Hsueh 2007; Hyman 2007; Jiang 2004;
Kendall 1987; Laitinen 1993; Logan 2010;Mahler 1999;Meland
1994;Micco 2007; Stewart 2005;Wong 2010; Zhao 2004) while
5 studies assessed diet adherence outcome (s) 3 or more times
(Miller 1988; Morey 2008; Ryan 2002; Scisney-Matlock 2006;
Tsay 2003). Consequently, 32 studies compared diet adherence
outcomes between an intervention group and a control/usual care
group, and 9 studies compared two intervention groups.
Excluded studies
As described in the Characteristics of excluded studies table, reasons
for exclusion included: no measure of adherence outcome;
not the same dietary advice component in groups; not a randomized
controlled trial; provision ofmeals, food, items or dietary supplements;
not involving clients with or at risk of chronic diseases;
intervention not intended to improve diet adherence; not a reallife
setting; clients were under the age of 18; and study did not
involve a nutritional intervention.
Risk of bias in included studies
As described in the Characteristics of included studies, eight risk
of bias criteria were applied to each study (random sequence generation,
allocation concealment, blinding: clients, providers and
outcome assessors, incomplete outcome data, selective reporting
and other bias). Two studies were rated as low risk on 4 of the
8 criteria (Gucciardi 2007; Zhao 2004), 8 studies were low risk
on 3 criteria (Aldarondo 1999; French 2008; Jiang 2004;Meland
1994; Morey 2008; Scisney-Matlock 2006; Stewart 2005; Tsay
2003), 11 studies were rated as low risk on 2 criteria (Arcand
2005; Assuncao 2010; Baraz 2010; Chen 2006; Cummings 1981;
Kendall 1987; Laitinen 1993; Logan 2010; Mahler 1999; Ryan
2002; Wong 2010), 11 studies were rated as low risk on one criterion
(Beasley 2008; Becker 1998; Bennett 1986; Blanson 2009;
Chiu 2010; Conrad 2000; Gill 2010, Hsueh 2007; McCulloch
1983; Miller 1988; Racelis 1998) and six studies were not rated
low risk for any criteria (Gans 1994; Grace 1996; Hyman 2007;
Jones 1986; Micco 2007; Wood 2008) (see Figure 2).
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 12
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Figure 2. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 13
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Allocation
The allocation sequence was adequately generated in the majority
of studies (n = 26). Twelve studies did not report sufficient information
to determine this risk of bias (Blanson 2009;Conrad 2000;
Gans 1994; Grace 1996; Hyman 2007; Jones 1986; McCulloch
1983; Micco 2007; Miller 1988; Racelis 1998; Tsay 2003; Wood
2008).
The allocation was adequately concealed only in seven studies
(Assuncao 2010; Jiang 2004; Laitinen 1993;Mahler 1999;Meland
1994; Stewart 2005; Zhao 2004) while nine studies reported
an inadequate allocation (Aldarondo 1999; Baraz 2010; Beasley
2008; Bennett 1986; Cummings 1981; Gucciardi 2007; Kendall
1987; Logan 2010;Miller 1988). The majority of the studies (n =
22) did not describe the allocation concealment in sufficient detail
to permit evaluation.
Blinding
The majority of the interventions provided to clients were difficult
to blind for clients, providers and outcomes assessors.
Therefore, only three studies (Aldarondo 1999; Blanson 2009;
Scisney-Matlock 2006), two studies (Gucciardi 2007; Tsay 2003)
and six studies (French 2008;Gucciardi 2007; Jiang 2004;Kendall
1987; Stewart 2005; Zhao 2004) respectively blinded clients,
providers and outcome assessors.
Incomplete outcome data
Twelve studies adequately addressed incomplete outcome data
(Aldarondo 1999; Arcand 2005; Baraz 2010; Chen 2006; Conrad
2000; McCulloch 1983; Meland 1994; Morey 2008; Racelis
1998; Ryan 2002; Tsay 2003; Zhao 2004) whereas 17 studies did
not (Assuncao 2010; Beasley 2008; Becker 1998; Bennett 1986;
Blanson 2009; Cummings 1981; Gucciardi 2007; Hyman 2007;
Jiang 2004; Jones 1986; Kendall 1987; Laitinen 1993; Logan
2010;Miller 1988; Stewart 2005;Wong 2010;Wood 2008). The
principal reason for the incomplete outcome data bias was that
missing outcomes are enough to induce clinically-relevant bias in
the observed effect estimate. Nine studies reported insufficient information
to permit an evaluation of this criterion (Chiu 2010;
French 2008; Gans 1994; Gill 2010, Grace 1996; Hsueh 2007;
Mahler 1999; Micco 2007; Scisney-Matlock 2006).
Selective reporting
Study protocols were available for only one study and all of the
study’s pre-specified outcomes that were of interest in the study
were reported in the pre-specified way. Therefore, only this study (
French 2008)was free of suggestion of selective outcome reporting.
Eighteen studies incompletely reported some outcomes of interest
(Aldarondo 1999; Assuncao 2010; Becker 1998; Conrad 2000;
Grace 1996; Hyman 2007; Jiang 2004; Kendall 1987; Laitinen
1993; Meland 1994; Micco 2007; Miller 1988; Morey 2008;
Racelis 1998; Ryan 2002; Stewart 2005;Wong 2010;Wood 2008)
whereas others provided insufficient information to address this
criterion (n = 19).
Other potential sources of bias
Eight studies (Cummings 1981; Gucciardi 2007; Logan 2010;
Miller 1988; Morey 2008; Scisney-Matlock 2006; Tsay 2003;
Wong 2010) appeared free of other potential sources of bias,
whereas 13 studies had at least one important risk of bias such
as a baseline imbalance between groups which was not taken into
consideration in statistical analyses, a diet adherence not clearly
defined, a diet adherence assessed by a non-validated self-reporting
method, a potential conflict of interest or a potential intervener
effect (Assuncao 2010; Beasley 2008; Becker 1998; Chiu 2010;
Conrad 2000; French 2008;Gans 1994;Grace 1996;Hsueh 2007;
Hyman 2007; Ryan 2002; Stewart 2005; Zhao 2004).Other studies
did not report sufficient information to assess other potential
sources of bias (n = 17).
Effects of interventions
Included studies differed widely according to interventions provided,
measures of diet adherence, dietary advice, nature of the
chronic diseases and duration of interventions and follow-up.
Therefore, data were not pooled statistically. Instead, we present a
qualitative analysis described in a narrative table using vote counting
for each category of interventions (see Additional tables). We
also created forest plots for outcomes from studies comparing a
single or multiple intervention group with a control/usual care
group (see Figure 3; Figure 4; Figure 5). Among the 32 studies
that measured diet adherence outcomes between an intervention
group and a control/usual care group, 32 out of 123 diet adherence
outcomes favoured the intervention group, 4 favoured the
control group whereas 62 had no significant difference between
groups. This result was impossible to assess for 25 diet adherence
outcomes as data and/or statistical analyses needed for comparison
between groups were not provided (Additional tables).
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 14
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Figure 3. Forest plot of comparison: 6 Nutritional tools versus control in diet adherence, outcome: 6.1
Continuous data. *Means represent the difference between pre-and post- intervention.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 15
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Figure 4. Forest plot of comparison: 8 Multiple interventions versus control in diet adherence, outcome: 8.1
Continuous data. *Means represent the difference between pre-and post- intervention.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 16
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Figure 5. Forest plot of comparison: 8 Multiple interventions versus control in diet adherence, outcome: 8.2
Dichotomous data. *Means represent the difference between pre-and post- intervention.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 17
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Education
See Table 1.
Counselling and follow-up with health professional
Telephone follow-up
Chiu 2010 assessed the effects of telephone follow-up on: adherence
to a sodium-restricted diet; fat intake and fruit and vegetable
intake, in clients with hypertension. The authors reported no differences
in diet adherence between the intervention group and the
control group at eight weeks. However, a greater decrease in systolic
and diastolic blood pressure was observed in the intervention
group compared to the control group as well as a greater increase
in exercise adherence.
One study (Cummings 1981) reported significantly higher adherence
to a potassium-restricted diet and fluid-restricted diet at six
weeks in clients with renal failure who received telephone followup,
compared to clients in the control group. However, these differenceswere
no longer significant at threemonths.This study also
compared clients with renal failure receiving telephone follow-up
with clients writing a formal agreement (contract) and with clients
writing a contract with the involvement of a family member or
friend, but found no differences in adherence to a potassium- and
fluid-restricted diet at three months between groups.
Racelis 1998 assessed the effects of telephone follow-up on adherence
to diet in clients with peripheral artery disease. The authors
indicated that no significant difference was noted between the intervention
and the control groups.
Stewart 2005 also evaluated the effects of telephone follow-up on
adherence to a sodium-restricted diet in clients with hypertension.
The authors reported that a higher proportion of clients adhered
to the sodium-restricted diet at 24 weeks in the intervention group
compared to the control group, but the difference was no longer
significant at 36 weeks. No differences were found in systolic and
diastolic blood pressure between groups. The authors also noted
no difference in non-adherence to alcohol intake at 24 and 36
weeks between groups.
Among studies using a control/usual care group, three out of ten
diet adherence outcomes favoured the intervention group compared
to control group and seven diet adherence outcomes had
no significant difference between groups (see Table 1). However,
these three diet adherence outcomes favouring the intervention
group were no longer significant at a later time point.
Group sessions
Gill 2010 evaluated the effects of group sessions in overweightobese
college women on adherence to the Dietary Approaches to
Stop Hypertension (DASH) diet. However, the authors did not
report measures of diet adherence for the intervention and the
control groups, making comparison between groups impossible.
Jones 1986 compared an intervention using group sessions (GS)
with three other groups for overweight clients: group sessions with
a dietitian combined with a leaflet providing advice to reduce exposure
to food cues (GS + cues); individual sessions with a dietitian
(IS); individual sessions with a dietitian combined with
a leaflet providing advice to reduce exposure to food cues (IS +
cues). Adherence to diet at 16 weeks was assessed but no significant
difference between groups was found. The SMD for weight
loss was calculated using RevMan software (RevMan 2012) and
no significant difference was found between groups at 16 weeks
(vs 1 SMD -0.24 (95% CI -1.22 to 0.75); vs 2 SMD -0.03 (95%
CI – 0.94 to 0.88); vs 3 SMD -0.55 (95% CI -1.55 to 0.46).
Overall, these studies did not allow us to draw conclusions on the
effect of group sessions on diet adherence outcomes (see Table 1).
Individual sessions with a dietitian
To assess the effects of a 16-week intervention promoting individual
sessions with a dietitian (IS), Jones 1986 compared this intervention
in overweight clients with three others: group sessions
with a dietitian (GS); 2) group sessions with a dietitian combined
with a leaflet providing advice to reduce exposure to food cues
(GS + cues); 3) individual sessions with a dietitian combined with
a leaflet providing advice to reduce exposure to food cues (IS +
cues). Adherence to diet at 16weekswas assessed but no significant
difference was found between groups. The SMD for weight loss
was calculated using RevMan 2012 and no significant difference
between groups was found at 16 weeks (vs 1 SMD 0.23 (95%
CI -0.46 to 0.93); vs 2 = SMD 0.30 (95% CI-0.69 to 1.08); vs 3
SMD 0.59 (95% CI -0.35 to 1.52).
Another study (Micco 2007) evaluated the effects of individual
sessions with a dietitian in overweight-obese clients on diet adherence.
The authors assessed diet adherence but they did not report
measures for the intervention and the control groups, making the
comparison between groups impossible. The authors reported no
weight loss difference between groups at 12 months.
Overall, these studies did not allow us to draw conclusions on
the effect of individual sessions with a dietitian on diet adherence
outcomes (see Table 1).
Individual sessions with a nurse
Hsueh 2007 compared a single intervention comprising individual
sessions with a nurse, on adherence to dietary advice to increase
fiber, vegetable and fruit intakes in clients with irritable bowel
syndrome, with a multiple intervention comprised of individual
sessions with a nurse alternating with telephone follow-up. The
authors reported no difference in the proportion of high-compliant
clients for fiber, vegetable and fruit intakes between groups at
three months and six months.
Educational tools
Video
One study (Baraz 2010) compared a single intervention using a
video as an educational tool with a multiple intervention using
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 18
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
a booklet as educational tool, combined with group sessions in
clients with chronic end-stage renal disease. The authors did not
report the proportion of clients classified as adherent to diet for
both groups, making a comparison between groups impossible.
The risk ratio (RR) for the proportion of clients who adhered to
the diet and fluid-restricted diet was calculated using RevMan and
no difference was found between groups at two months for diet
(RR 0.48 (95% CI 0.17 to 1.35)) and fluid-restricted diet (RR
0.81 (95% CI 0.25 to 2.57)).
Mahler 1999 evaluated the effects of a video as an educational
tool on adherence to a cholesterol and saturated fat-restricted diet
in clients with coronary artery disease. Adherence to a cholesterol
and saturated fat-restricted diet was significantly higher in the intervention
group compared to the control group at one month
but this difference was no longer significant at three months. The
authors also compared the intervention with another intervention
using a video as an educational tool combined with relapse prevention/
coping planning, and found no difference between groups.
Another study (McCulloch 1983) reported a significant difference
in day-to-day consistency in carbohydrate intake in clients
with insulin dependent diabetes receiving an intervention using
a video as an educational tool, compared to the usual care group
at six months. Moreover, glycated haemoglobin (HbA1c) was significantly
lower in the intervention group than in the usual care
group at six months. The authors also compared the intervention
with another intervention using nutritional tool and no difference
between groups was noted.
Among studies using a control/usual care group, two out of three
diet adherence outcomes favoured the intervention group compared
to the control/usual care group and one diet adherence outcome
had no significant difference between groups (see Table 1).
However, one out of two diet adherence outcomes favouring the
intervention group was no longer significant at a later time point.
Booklet
Kendall 1987 compared an intervention using a booklet as an educational
tool with an intervention using exchange lists as a nutritional
tool in clients with non-insulin-dependent diabetes. No
difference between groups was reported for adherence to energy,
protein, vitamin A, vitamin C, thiamine, riboflavin, niacin, calcium,
phosphorus, iron and zinc intakes at three and six months.
Moreover, there was no difference between groups for health
outcomes such as systolic and diastolic blood pressure, weight,
plasma glucose, HbA1c, serum cholesterol, low-density lipoprotein
(LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol
and serum triglycerides at six months.
Persuasion
See Table 2.
Reminders
Gans 1994 compared three interventions using reminders with
a usual care group in clients with elevated blood cholesterol: 1)
clients received the reminder, 2) physicians received a reminder
postcard which they could mail to the clients, 3) clients received
the reminder in addition to the physicianswho received a reminder
postcardwhich they couldmail to the clients.The authors reported
no difference in the proportion of clients that adhered to diet in
any of these groups compared to the usual care group at three
months, and no difference between groups for the compliance to
lifestyle recommendations at three months.
Another study (Ryan 2002) compared two interventions using
knowledge and self-care practices as reminders with a control
group in clients with type II diabetes: 1) reminders provided to
clients at two weeks, three months and six months, 2) reminders
provided to clients at three months and six months. The authors
reported adherence to frequency ofmeals and snacks combined for
all three groups, making comparison between groups impossible.
Overall, the studies used reminders for patients and physicians
(Gans 1994) or for patients (Ryan 2002) to enhance adherence to
dietary advice. Among studies using a control/usual care group,
three out of 19 diet adherence outcomes had no significant difference
between groups. It was impossible to assess this result for
16 diet adherence outcomes since data and/or statistical analyses
needed for comparison between groups were not provided (see
Table 2).
Incentivisation
See Table 3.
Contracts with rewards
One study (Cummings 1981) reported significantly higher adherence
to a potassium-restricted diet and to a fluid-restricted diet at
six weeks in clients with renal failure who wrote a behavioural contract,
compared to clients in the control group (see Table 3).However,
these differences were no longer significant at three months
(see Table 3). This study also compared clients with renal failure
writing a contract with clients receiving telephone follow-up and
with clients writing a contract with the involvement of a family
member or friend but no difference was noted in adherence to the
potassium-restricted diet and fluid-restricted diet at six weeks and
three months between groups.
Training
See Table 4.
Feedback
Beasley 2008 reported a higher adherence to energy, fat, saturated
fat and cholesterol intakes in overweight-obese clients in the intervention
group using feedback based on self-monitoring using
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 19
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
an electronic food diary compared to the control group. However,
no difference in weight loss was observed between groups.
French 2008 compared two interventions using feedback based
on self-monitoring of blood glucose with a usual care group in
clients with type II diabetes: 1) less intensive intervention, 2)most
intensive intervention. Adherence to general and specific diet at
12 months was greater in the control group compared to both
intervention groups.
Another study (Meland 1994) assessed the effects of feedback using
self-monitoring of urine chloride concentration on adherence to a
sodium-restricted diet in clients with hypertension. No difference
was reported in adherence to the sodium-restricted diet or in blood
pressure between the intervention group and the control group at
one and three months.
In this category, three studies used feedback based on self-monitoring
using an electronic food diary (Beasley 2008), blood glucose
(French 2008) and urine chloride concentration (Meland 1994).
Among studies using a control/usual care group, one out of seven
diet adherence outcomes favoured the intervention group compared
to the control/usual care group, four favoured the control
group whereas two had no significant difference between groups
(see Table 4).
Restriction
See Table 5.
Conrad 2000 assessed the effects of an intervention proposing an
incremental reduction in fat to a goal of 10% of energy intake
compared to an intervention proposing an immediate reduction
in fat to a goal of 10% of energy intake in clients with coronary
artery disease.The authors did not compare adherence to fat intake
advice between groups. Therefore, we calculated the SMD for
adherence to the very low fat diet using RevMan 2012 and found
no differences between groups at sevenmonths (SMD-1.88 (95%
CI -4.00 to 0.23)) (see also Table 5).
Modelling
See Table 6.
Nutritional tools
Assuncao 2010 assessed the effects of nutritional tools such as
portion size examples and food lists on diet adherence in overweight-
obese clients using an intention-to-treat analysis. Authors
reported a significant enhancement of adherence to sodium and
sweet food intake goals at six months in clients in the intervention
group compared with those receiving usual care. However, a discrepancy
was found between the results provided by the authors
and the SMD calculated using RevMan which showed no difference
for adherence to sweet food intake at six months between
groups. No difference was found between groups for adherence
to recommended energy, protein, fat, carbohydrate, cholesterol,
fiber, fruit and vegetable intakes (see Analysis 1.1). An increase in
physical leisure activity as well as a decrease in fasting glucose were
reported in the intervention compared to the usual care group at
six months, whereas no difference between groups was observed
for weight loss, blood pressure and lipid profile.
Chen 2006 reported a higher proportion of intervention-group
clients with renal failure reaching the target for protein intake at
one month using menu suggestions, exchange lists and portion
sizes as nutritional tools compared to the control group.
Grace 1996 evaluated the effects of nutritional tools such as an additional
package containing low-fat cooking methods and low-fat
recipe adaptation on adherence to energy and fat intakes in clients
with hyperlipidaemia. The authors reported a higher reduction in
percentage of fat intake in the intervention group compared to
the control group. However, they reported no difference for energy
change between the intervention and the control groups at
12 weeks (see also Analysis 1.1).
Kendall 1987 compared an intervention using exchange lists as a
nutritional tool with an intervention using a booklet as an educational
tool in clients with non-insulin-dependent diabetes.No difference
between groups was reported for adherence to energy, protein,
vitamin A, vitamin C, thiamine, riboflavin, niacin, calcium,
phosphorus, iron and zinc intakes at three and six months. Moreover,
there was no difference between groups for health outcomes
such as systolic and diastolic blood pressure, weight, plasma glucose,
HbA1c, serum cholesterol, LDL-cholesterol, HDL-cholesterol
and serum triglycerides at six months.
One study (Logan 2010) compared an intervention using recipes
and meal plans with an intervention using barrier identification/
problem solving and goal setting in clients with coronary heart
disease. The authors reported no difference between groups for
adherence to the Mediterranean diet at 6 and 12 months.
Another study (McCulloch 1983) reported no difference in dayto-
day consistency in carbohydrate intake in clients with insulindependent
diabetes following an intervention using exchange lists
and lunch time with health professionals as nutritional tools, compared
to usual care group.However,HbA1c was significantly lower
in the intervention group at 9 months compared to the control
group. The authors also compared the intervention with another
intervention using a video as an educational tool and found no
difference between groups.
Scisney-Matlock 2006 evaluated the effects of wheels and bar
charts displaying Cognitive Representations of the DASH diet
as a nutritional tool on adherence to the DASH diet in clients
with hypertension compared to a control group. The authors reported
results grouped for both groups, making comparison between
groups impossible.
To summarize the interventions in this category: two studies included
portion sizes (Assuncao 2010; Chen 2006), three studies
used menu suggestions and recipes (Chen 2006; Grace 1996;
Logan 2010), three studies included exchange lists (Chen 2006;
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 20
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Kendall 1987; McCulloch 1983), one study used an additional
package containing low-fat cooking methods (Grace 1996), one
study used lunch time with health professionals (McCulloch
1983), and one study used wheels and bar charts displaying Cognitive
Representations of the DASH diet (Scisney-Matlock 2006)
as nutritional tools in their intervention.
Among studies using a control/usual care group, 3 out of 17 diet
adherence outcomes favoured the intervention group and 11 diet
adherence outcomes had no significant difference between groups.
It was impossible to assess this result for three diet adherence outcomes
as data and/or statistical analyses needed for comparison
between groups were not provided (Table 6).
Enablement
See Table 7.
Behaviour change techniques
Aldarondo 1999 reported no difference in adherence to energy,
fat and saturated fat intake at 14 weeks between the intervention
group using barrier identification/problem solving and self-talk
compared to the control group in obese clients.
Another study (Bennett 1986) compared three interventions using
behavioural change techniques in overweight-obese clients: 1)
teaching clients to use prompts/cues, 2) self-talk, 3) barrier identification/
problem solving. The authors reported that clients in the
intervention group using food cues adheredmore closely to energy
intake goals than those in the two other groups between baseline
and 15 weeks.
One study (Logan 2010) compared an intervention using barrier
identification/problem solving and goal setting with an intervention
using recipes and meal plans as nutritional tools in clients
with coronary heart disease. The authors reported no difference
between groups for adherence to the Mediterranean diet at 6 and
12 months.
Overall, in this category: three studies used behavioural change
techniques such as barrier identification/problem solving and selftalk
(Aldarondo 1999), teaching clients to use prompts/cues, selftalk
and barrier identification/problem solving (Bennett 1986)
and barrier identification/problem solving and goal setting (Logan
2010).
Only one study used a control group and three out of three diet
adherence outcomes had no difference between groups (see Table
7).
Multiple interventions
See Table 8.
Arcand 2005 evaluated the effects of individual sessions with a dietitian
combined with goal setting, on adherence to a sodium-restricted
diet in clients with heart failure. The authors did not compare
adherence to the sodium-restricted diet nor blood pressure
between groups. Therefore, we calculated the SMD for adherence
to the sodium-restricted diet and blood pressure using RevMan,
and found no difference between groups for sodium-restricted diet
(see also Analysis 2.1), systolic blood pressure (SMD-0.30 (95%
CI -0.88 to 0.27)) and diastolic blood pressure (SMD-0.53 (95%
CI -1.11 to 0.05)).
One study (Baraz 2010) compared a multiple intervention using
a booklet as educational tool combined with group sessions,
with a single intervention using a video as an educational tool,
in clients with chronic end-stage renal disease. The authors did
not report the proportion of clients classified as adherent to diet
for both groups, making comparison between groups impossible.
Therefore, we calculated the RR for the proportion of clients who
adhered to the diet and fluid-restricted diet at two months, using
RevMan, and found no difference between groups.
Using an intention-to-treat analysis, Becker 1998 reported no
difference in the proportion of clients at risk of coronary heart
disease who received telephone follow-up combined with a barrier
identification/problem solving intervention for adherence to
a fat-restricted diet at two years, compared to clients in the usual
care group. Moreover, no difference was found for LDL-cholesterol,
HDL-cholesterol and triglyceride levels at two years between
groups.
Blanson 2009 evaluated the effects of self-monitoring using a computer
assistant combined with feedback using motivational interviewing
in overweight clients. They reported no significant difference
in adherence to diet at 28 days between the intervention and
the control groups.
Cummings 1981 reported a significantly higher adherence to a
fluid-restricted diet at six weeks in clients with renal failure asked
to write a formal agreement (contract) with the involvement of
a family member or friend, compared to clients in the control
group. However, these differences were no longer significant at
three months. This study also compared clients writing a formal
agreement (contract) with the involvement of a family member
or friend, with clients writing a contract, and with clients who
received telephone follow-up, but no differences in adherence to
a potassium- and fluid-restricted diet at three months were found
between groups.
In type II diabetes clients, the comparison of an intervention using
group sessions and nutritional tools combined with barrier identification/
problem solving versus control (Gucciardi 2007) showed
a higher adherence to dietary advice in the intervention group
at three months. However, the authors reported no difference in
HbA1c between the groups at threemonths (see also Analysis 2.1).
Hsueh 2007 compared a multiple intervention comprising individual
sessions with a nurse alternating with telephone follow-up
on adherence to fiber, vegetable and fruit intakes in clients with
irritable bowel syndrome, with a single intervention comprising
individual sessions with a nurse. The authors reported no differ-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 21
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ence in the proportion of high-compliant clients for fiber, vegetable
and fruit intakes between groups at three and six months.
To assess the effectiveness of an intervention using telephone follow-
up combined with motivational interviewing, Hyman 2007
compared two interventions in clients with hypertension with a
usual care group: 1) simultaneous behaviour change (stop smoking,
reduce dietary sodium level and increase physical activity); 2)
sequential behaviour change (stop smoking, then reduce dietary
sodium levels and finally increase physical activity). A higher proportion
of clients adhered to the sodium-restricted diet in the simultaneous
group, compared to the sequential intervention and
the usual care group at six months, but no difference was observed
at 18 months. No difference was reported for blood pressure between
groups (see also Analysis 2.2).
Jiang 2004 assessed the effects of an intervention using individual
sessions with a nurse and telephone follow-up combined with goal
setting, on adherence to the Adult Treatment Panel (ATP) step
II diet (hypocholesteraemic diet) in clients with angina pectoris
or myocardial infarction. Using an intention-to-treat analysis, the
authors reported better adherence to the step II diet in the intervention
group compared to the usual care group at three and
six months. At three months, triglyceride, total cholesterol, LDLcholesterol
levels and blood pressure decreased significantly more
in the intervention group than the usual care group, while no difference
was noted for HDL-cholesterol and body weight. At six
months, only the differences in triglyceride, total cholesterol and
LDL-cholesterol levels remained significant.
Jones 1986 compared four interventions in overweight clients:
group sessions with a dietitian (GS); group sessions with a dietitian
combined with a leaflet providing advice to reduce exposure
to food cues (GS + cues); individual sessions with a dietitian (IS);
individual sessions with a dietitian combined with a leaflet providing
advice to reduce exposure to food cues (IS + cues). The authors
found no significant difference between groups for adherence to
diet, as well as for weight loss, at 16 weeks.
Laitinen 1993 evaluated the effects of individual sessions with a
dietitian and nutritional tools combined with goal setting, on adherence
to total fat, saturated fat, unsaturated fat, carbohydrate,
fiber and cholesterol advice in clients with non-insulin-dependent
diabetes. Although the authors reported no differences for total,
saturated and unsaturated fat intake at three months, there was a
higher proportion of clients who adhered to total and saturated
fat intake recommendations in the intervention group compared
to the usual care group at 15 months, whereas a higher proportion
of clients adhered to unsaturated fat in the usual care group at 15
months. However, a discrepancy was found between the results
provided by the authors and the RR calculated using RevMan
which revealed no difference for adherence in total fat and unsaturated
fat at 15 months between groups. Fasting blood glucose
andHbA1c decreased significantly more in the intervention group
at 15 months than in the control group, while no difference was
noted for body weight, total cholesterol and HDL-cholesterol levels.
From data provided by the authors, we used RevMan to calculate
the SMD for the proportion of clients who adhered to carbohydrate,
fiber and cholesterol intakes, and found no differences
between groups at 3 and 15 months (see also Analysis 2.2).
Mahler 1999 assessed the effects of a video as educational tool combined
with relapse prevention/coping planning on adherence to a
cholesterol- and saturated fat-restricted diet in clients with coronary
artery disease. Adherence to a cholesterol- and saturated fatrestricted
diet was significantly higher in the intervention group
compared to the control group at one month, but this difference
was no longer significant at three months. The authors also compared
the intervention with another intervention using a video as
an educational tool, and found no difference between groups.
Miller 1988 evaluated the effects of individual sessions with a dietitian
combined with barrier identification/problem solving and
goal setting in clients with myocardial infarction. While no difference
was found at 30 days, 60 days and 1 year, the authors reported
a significant difference in adherence to diet at 2 years between the
intervention and the control groups.
Morey 2008 compared an intervention including individual sessions
with a nurse, a booklet as educational tool and reminders
combinedwithmotivational interviewing interventionwith a control
group. They reported a higher proportion of clients with endstage
kidney disease adhering to a phosphate-restricted diet at three
months in the intervention group compared to the control group.
Data for adherence to the phosphate-restricted diet at 6 and 12
months were not reported (see also Analysis 2.2).
A multiple intervention (Tsay 2003) including self-monitoring in
a diary and feedback combined with stress management and goal
setting in clients with end-stage renal disease showed a significant
group main effect in adherence to a fluid-restricted diet when
baseline mean weight gains were applied as covariate. From data
provided by the authors, we used RevMan to calculate the SMD
for adherence to a fluid-restricted diet at 1month, 3months and 6
months, respectively. No difference was found between groups at
onemonth but adherence to a fluid-restricted diet at threemonths
and six months was significantly higher in the intervention group
compared to the control group (see also Analysis 2.1).
Wong 2010 reported a difference in the degree of non-adherence
to diet at sevenweeks in clientswith renal failurewho received telephone
follow-up combined with goal setting compared to clients
in the control group. However, a discrepancy was found between
the results provided by the authors and the SMD calculated using
RevMan which revealed no difference for the degree of non-adherence
to diet at seven weeks between groups. No difference was
found between groups for the degree of non-adherence to diet at
13 weeks and for the number of days of non-adherence to diet, as
well as non-adherence to fluid restriction (degree and days) at 7
and 13 weeks (see also Analysis 2.1).
Wood 2008 studied two populations: clients with coronary heart
disease and clients at high risk of the disease. In clients with coronary
heart disease, the authors reported a higher proportion of
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Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
clients achieving the target for saturated fat, oily fish and fruit and
vegetable intakes at one year in the intervention group (individual
sessions with a nurse combined with motivational interviewing)
compared to the usual care group. No difference was observed
in adherence to fish consumption advice between groups. However,
a discrepancy was found between the results provided by the
authors and the RR calculated using RevMan which revealed a
higher proportion of clients achieving the target for fish intake in
the intervention group. A higher proportion of clients achieved
the target for blood pressure in the intervention group compared
to the usual care group, while no difference was found for body
weight, and total and LDL-cholesterol levels. In clients at high risk
of coronary heart disease, a higher proportion of clients achieving
the target of fruit and vegetable intakes was reported at one year in
the intervention group, while no difference was observed in adherence
to recommended fish and oily fish intakes between groups.
However, a discrepancy was found between the results provided by
the authors and the RR calculated using RevMan which revealed
a higher proportion of clients achieving the target for oily fish
and fish intake in the intervention group. A higher proportion of
clients also achieved the target for blood pressure and body weight
in the intervention group compared to the usual care group while
no difference was found for total and LDL-cholesterol levels (see
also Analysis 2.2).
One study (Zhao 2004) evaluating the effects of telephone followup
as well as individual sessions with a dietitian combined with
goal setting in clients with coronary heart disease reported a higher
proportion of clients with high adherence to diet in the intervention
group compared to the usual care group at 4 and 12 weeks
(see also Analysis 2.2).
Overall, in this category, 13 studies combined an educational interventionwith
another intervention such as an enablement intervention
(Arcand 2005; Becker 1998; Gucciardi 2007; Hyman 2007;
Jones 1986,Mahler 1999;Miller 1988;Wong 2010;Wood 2008;
Zhao 2004), modelling and enablement interventions (Laitinen
1993), persuasion and enablement interventions (Morey 2008),
and two educational interventions with enablement interventions
(Jiang 2004). Two studies combined two different educational interventions
(Baraz 2010; Hsueh 2007). One study combined a
training intervention with an enablement intervention (Blanson
2009) and one study combined two enablement interventions and
a training intervention (Tsay 2003). One study combined an incentivisation
with a persuasion intervention (Cummings 1981).
In this category, among studies using a control/usual care group,
21 out of 56 diet adherence outcomes favoured the intervention
group whereas 32 diet adherence outcomes had no significant
difference between groups. Itwas impossible to assess this result for
three diet adherence outcomes as data and/or statistical analyses
needed for comparison between groups were not provided (Table
8). However, 4 out of 21 diet adherence outcomes favouring the
intervention group was no longer significant at a later time point.
D I S C U S S I O N
Summary of main results
This review included 38 studies investigating the effects of interventions
enhancing adherence to dietary advice for preventing
and managing chronic diseases in adults. Studies reporting at least
one diet adherence outcome showing statistically significant differences
favouring the intervention group included the following
interventions: telephone follow-up, video, contract, feedback, nutritional
tools and multiple interventions. However, these interventions
also showed no difference in some diet adherence outcomes
compared to a control/usual care group. Moreover, the included
studies differedwidely according to interventions provided,
measures of diet adherence, dietary advice, nature of the chronic
diseases and duration of interventions and follow-up.
The majority of these studies were conducted in United States of
America. Cardiovascular disease, diabetes, hypertension, and renal
diseases were the most frequently studied chronic diseases. The
adoption of a healthy diet is recommended as a prevention ormanagement
strategy for each of these chronic diseases (Lichtenstein
2006; Bantle 2008; Kopple 2001). Interestingly, all studies including
clients with renal diseases reported at least one diet adherence
outcome showing a statistically significant difference favouring the
intervention group, no matter which intervention was provided.
Only 10 of the 38 included studies evaluated diet adherence to
dietary advice over a 12-month period (Becker 1998; French
2008; Hyman 2007; Laitinen 1993; Logan 2010; Micco 2007;
Miller 1988; Morey 2008; Racelis 1998; Wood 2008). Among
those 10 studies, only three studies showed at least one statistically
significant difference in diet adherence outcomes favouring the
intervention group over a 12-month period.
A broad range of interventions, all related to themethod for changing
dietary habits through dietary advice, was covered in this review,
including education (telephone follow-up, group sessions,
individual sessions with a dietitian or a nurse, and educational
tools (video or booklet)), persuasion (reminders), incentivisation
(contracts with rewards), training (feedback), restriction, modelling
(nutritional tools) and enablement (behaviour change techniques).
However, the majority of studies included a combination
of two or more different interventions.
This review included studies comparing one or more intervention
group(s) with one control/usual care group, but also studies
comparing two or more intervention groups to each other. However,
only comparisons made between an intervention group and
a control/usual care group allowed the evaluation of the effect of
the intervention alone on adherence to dietary advice. Therefore,
among studies thatmeasured diet adherence outcomes between an
intervention group and a control/usual care group, 32 out of 123
diet adherence outcomes favoured the intervention group. More
specifically, studies reporting at least one diet adherence outcome
showing statistically significant differences favouring the intervention
group included the following interventions: telephone fol-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 23
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
low-up (3 out of 10 diet adherence outcomes), video (2 out of
3 diet adherence outcomes), contract (2 out of 4 diet adherence
outcomes), feedback (1 out of 7 diet adherence outcomes), nutritional
tools (3 out of 17 diet adherence outcomes) and multiple
interventions (21 out of 56 diet adherence outcomes). Studies
investigating interventions such as a group session, individual
session, reminders, restriction and behaviour change techniques
reported no diet adherence outcome showing a statistically significant
difference favouring the intervention group. However, these
results should be interpreted with caution as several studies evaluated
two or more diet adherence outcomes. Among those, most of
the studies showing a statistically significant difference favouring
the intervention group for diet adherence outcome(s) also showed
no significant differences between groups for other diet adherence
outcome(s) (Assuncao 2010; Cummings 1981; Grace 1996;
Hyman 2007; Laitinen 1993; Mahler 1999; McCulloch 1983;
Miller 1988; Stewart 2005; Tsay 2003). For example, Laitinen
1993 assessed the effects of a multiple intervention and reported
better adherence to saturated fat intake at 15 months in the intervention
group whereas no differences were observed for adherence
to intake of total, saturated or unsaturated fat carbohydrate,
fiber or cholesterol between the intervention group and the control
group at either 3 or 15 months. In addition, where studies
measured outcomes at multiple time points, the majority of studies
reporting a diet adherence outcome favouring the intervention
group compared to the control/usual care group in the short-term
also reported no significant effect at later time points. Interestingly,
the majority of studies involving multiple interventions reported
positive results on adherence to dietary advice. However, because
multiple components within these interventions acted as co-interventions,
it may have introduced confounding effects. Therefore,
drawing conclusions about whether the interventions enhanced
adherence to dietary advice is very difficult.
Overall completeness and applicability of
evidence
Although we included a substantial number of studies covering a
broad range of chronic diseases and interventions, very few studies
assessing a specific chronic disease condition evaluated the same
intervention. In addition, measures of adherence and dietary advice
varied widely across studies.
This review assessed the effects on adherence related to the intervention
alone since only the intervention, related to the method
for facilitating changes in dietary habits through dietary advice,
differed between the intervention group and the control/usual care
group. Comparisons between two or more intervention groups
were also reported. However, comparisons between multiple interventions
were all different. In order to isolate the effects of the
intervention, both clients in the intervention group and the control/
usual care group received the same dietary advice related to
their chronic disease condition. This situation could explain why
adherence to dietary advice in the control/usual care group increased
in some studies. However, factors other than the intervention
provided could have affected adherence to dietary advice.
For example, clients’ intrinsic characteristics such as an elevated
level of self-efficacy (Mishali 2011; Aljasem 2001) as well as few
perceived barriers (Walsh 2011) are associated with better dietary
adherence in clients with chronic diseases. Some studies also reported
that the client’s stage of change based on the Transtheoretical
Model predicted long-term changes in dietary behaviours
(Mochari 2010; Blissmer 2010). Therefore, confounding factors
should be taken into consideration in studies evaluating adherence
to dietary advice.
In this review, secondary outcomes related directly to the chronic
disease condition (e.g.HbA1c and/or blood glucose in clients with
diabetes, weight for clients with obesity) were reported. Few studies
reported other secondary outcomes such as process measures,
services outcomes and harms or secondary effects, making interpretation
about these secondary outcomes impossible. Fourteen
studies comparing an intervention group with a control/usual care
group also reported clinical and/or biochemical outcome(s) in addition
to adherence to dietary advice. Among those, six reported
improvement in at least one chronic disease-related clinical or biochemical
outcome in the intervention group. Asmentioned earlier,
these results should be interpreted with caution as several studies
evaluated two or more clinical and/or biochemical outcomes.
Seventeen studies provided advice in order to induce changes other
than diet such as physical activity, medication compliance, smoking
cessation and blood glucose monitoring. All of these studies
independently assessed adherence to dietary advice, but because
those studies varied widely according to interventions provided
and nature of the chronic diseases, we cannot conclude that adherence
to dietary advice is improved whenmultifaceted interventions
are provided.
Quality of the evidence
Despite a high number of included studies (n = 38), these studies
varied widely according to interventions provided, measures of
diet adherence, dietary advice, nature of the chronic diseases and
duration of interventions and follow-up. The numbers of clients
included in the review is impressive (9445), but the range of number
of clients in each study was wide, varying from 7 to 5405
clients. Only 13 of the 38 included studies provided a power calculation
(Aldarondo 1999; Assuncao 2010; Beasley 2008; Chiu
2010; French 2008; Hyman 2007; Jiang 2004; Meland 1994;
Stewart 2005; Tsay 2003; Wong 2010; Wood 2008; Zhao 2004)
and among them, 10 studies recruited the number of clients according
to their power analysis (Aldarondo 1999; Assuncao 2010;
Beasley 2008; French 2008; Jiang 2004; Meland 1994; Stewart
2005; Tsay 2003; Wong 2010; Zhao 2004).
While an elevated drop-out rate could be considered as an indirect
measure of non-adherence, such as in studies of pharmaceutical
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 24
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
interventions where participants who withdraw no longer have
access to medication, it cannot be assumed that clients dropping
out of dietary intervention studies are non-adherent to dietary advice.
Most studies included in this review had a low drop-out rate.
In fact, 19 studies reported a drop-out rate lower than 20% (9
of those had no drop-out). Nine studies had a drop-out rate of
between 20% and 30% and only five studies had a drop-out rate
over 30%. It was impossible to calculate the drop-out rate for six
studies (Gans 1994; Gill 2010; Hsueh 2007; Jones 1986; Mahler
1999; McCulloch 1983). One study (Wood 2008) reported adherence
for two populations, which explains why the total number
of included studies adds up to 39, and not 38.
The majority of included studies were of poor methodological
quality and/or poorly reported risk of bias elements. All included
studies met less than five of the eight criteria of risk of bias (see
Assessment of risk of bias in included studies). Among those eight
criteria, three of themevaluated respectively the blinding of clients,
providers and outcome assessors. Very few included studies met
these criteria because blinding in the context of delivering a nutritional
intervention is very difficult to achieve, even impossible in
some designs. Unlike most pharmaceutical designs using placebo,
both clients and providers from nutritional studies usually know
which intervention is delivered.
Amajor challenge in themeasurement of diet adherence is the correct
estimation of dietary intake, as no method for accurate determination
of dietary intake has been developed yet. In this review,
31 studies used self-reported measures of diet adherence while 6
studies assessed diet adherence using objectivemeasures.Objective
measures included serummicronutrients (e.g. potassium, sodium,
phosphate) and interdialytic weight gain to evaluate respectively
adherence to diet and to fluid-restricted diet in clients with renal
diseases, and urinary electrolytes excretion (sodium, chloride)
to evaluate adherence to a sodium-restricted diet in clients with
hypertension. Those methods have been validated and are usually
more reliable than self-reported measures. However, the assessment
of many food and nutrient intakes cannot always be
performed by objective measures, especially when dietary advice
targets food groups (e.g. fruit and vegetables) rather than a specific
nutrient (e.g. sodium). The Academy of Nutrition and Dietetics
states that “total diet or overall pattern of food eaten is the
most important focus of a healthful eating style” (JADA 2007).
Consequently, most studies providing dietary advice focusing on
a global healthy diet rather than a specific nutrient used self-reported
methods such as dietary tools (e.g. food records, food frequency
questionnaires and validated diet questionnaires or scales).
Misreporting of dietary intake is amajor issue and has been related
to body mass index, age, sex, socio-economic status and education
(Poslusna 2009). In addition, other sources of misreporting have
been identified such asmemory relapses,misrepresentation of portion
size consumed, social desirability and daily dietary variability
(Kumanyika 2000;Wilson 2005). Therefore, establishing validity
and reliability of dietary tools is crucial in order to avoid inconsistent
estimates of dietary intake leading to a high risk of bias. In this
review, only 14 studies of 32 stated that the self-reportedmeasures
of diet adherence had been validated and/or shown to be reliable,
suggesting that adherence to dietary advice in those studies could
be biased. To gain a thorough understanding of adherence to dietary
advice, both self-report and objective measures of adherence
are needed.While objectivemeasures provide information on food
intake only, self-report measures also provide useful information
on the circumstances of non-adherence. The latter is important
for clinicians to understand the reasons why the client is non-adherent
(which may include the clinicians’ lack of behavioral skills)
and to promote a collaborative relationship that considers clients’
values and preferences. More research is therefore needed to both
develop standardized and validated self-report adherencemeasures
and to identify more robust and objective measures of adherence
to dietary advice.
Potential biases in the review process
Strengths of this review include the fact that we contacted many
study authors during the data extraction process to gather additional
information. The main reason was that some authors did
not adequately describe the intervention provided in the intervention
group and/or in the control/usual care group, in the published
report. Additional information we received allowed us to
better classify the included studies according to the intervention
provided.
As expected, a limitation of this review is the definition of adherence
to dietary advice. Adherence to dietary advice is a wide concept
and includes many differentmeasures including self-reported
measures which are not always comparable. Accordingly, in this
review, some included studies assessed adherence to dietary advice
by reporting the proportion of clients achieving the dietary recommendations.
However, the majority of included studies evaluated
adherence to dietary advice by comparing themean dietary intake
between groups. These different ways to measure adherence to dietary
advice suggest that there is a need to develop standardized
and validated tools to assess adherence to dietary advice.
In this review, we only included studies clearlymentioning a measure
of adherence to dietary advice in the title or the objective of
the study and/or those reporting the proportion of clients adhering
to dietary advice. Therefore, we excluded all studies reporting
mean dietary intake between groups without specifically assessing
adherence to dietary advice as a primary outcome. Despite
an extensive search in standard databases as well as in the grey
literature, we cannot exclude the possibility that we missed some
studies measuring adherence to dietary advice if those studies were
not indexed in bibliographic databases as reporting adherence or
compliance.
We categorized interventions according to Michie et al (Michie
2011) intervention functions to simplify and structure the presentation
of results and not to provide insights about which in-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 25
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
tervention function was most effective for enhancing adherence
to dietary advice. Although two review authors assigned the interventions
to the categories through consensus, the assignment
was arbitrary and we cannot exclude the fact that others may have
assigned interventions to other categories. However, it must be
emphasized that the process did not interfere with the interpretation
of results.
Agreements and disagreements with other
studies or reviews
Few systematic reviews evaluated clients’ adherence to recommendations
in the context of preventing and/or managing chronic diseases.
Among systematic reviews reporting the effectiveness of interventions
to enhance adherence to dietary advice, none assessed
the same criteria as this review, making comparisons difficult. For
example, two systematic reviews included other components in
the assessment of adherence in addition to diet, such as physical
activity and medication (Matteson 2010; Greaves 2011). The
evaluation of diet adherence alone for those studies was therefore
impossible. Fappa et al (Fappa 2008) performed a non-systematic
review on lifestyle interventions for enhancing adherence to diet
and exercise in themanagement of themetabolic syndrome.However,
dietary advice provided in the majority of included studies
differed between the intervention and the control groups. Consequently,
the effects of the intervention could not be isolated.
Burke 1997 conducted a non-systematic review of successful
strategies to increase adherence to dietary advice in the context of
CVD prevention. Among eleven included studies, interventions
found to be effective to improve adherence to nutritional therapy
were behavioural skill training, spouse support and self-efficacy
enhancement.
Our results are consistent with those of Brownell and colleagues
(Brownell 1995b) who performed an overview of studies with diet
adherence data. They reported inconsistencies in methods and
had difficulty interpreting results because of the broad variation of
diseases covered and interventions provided. Similarly,Newell et al
(Newell 2000) performed a non-systematic review of strategies for
improving cardiovascular client compliance to non-pharmacologic
treatments. No strong evidence was reported for the enhancement
of dietary regime, and studies included were assessed as fair quality
in term of study design. Those conclusions underline the fact
that further good-quality studies assessing adherence to dietary
advice for preventing and managing chronic diseases should be
performed.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
Non-adherence to dietary advice represents one of the barriers
to getting nutrition knowledge into practice, thereby potentially
hampering the prevention of the onset or progression of many
chronic diseases and ultimately, improved population well-being
and health. This Cochrane review aimed to summarize, categorize
and compare the effects of interventions for enhancing adherence
to dietary advice for preventing and managing chronic diseases
in adults. Some interventions such as telephone follow-up, video,
contract, feedback and nutritional tools demonstrated a mixed effect
on diet adherence as they showed some diet adherence outcomes
favouring the intervention group compared to the control/
usual care group but also no difference in some diet adherence outcomes
between groups.Moreover, included studies differed widely
according to interventions provided, measures of diet adherence,
dietary advice, nature of the chronic diseases and duration of interventions
and follow-up, making assessment of intervention versus
intervention rather challenging. Therefore, this systematic review
cannot draw firm conclusions from comparisons between interventions,
but rather identifies a number of potentially-beneficial
interventions that can be used in practice (telephone follow-up,
video, contract, feedback and nutritional tools). Also, while the
majority of multiple interventions have demonstrated a positive
effect on diet adherence compared to a control/usual care group,
none of the included studies assessed the same combination of
interventions, making impossible the identification of the optimal
combination of interventions to enhance adherence to dietary
advice. Consequently, researchers, decision makers, health professionals
and consumers remain with little practical guidance with
regard to the best intervention for enhancing adherence to dietary
advice. However, it may be argued that in health care, there is often
no unique best option for either treatment or process of care,
as these options may be influenced by clients’ preferences and values.
Although longer-term, well-designed RCTs using improved
methods for measuring diet adherence are needed, results of this
systematic review provide options for both health professionals
and consumers that may be used in practice. Interventions shown
to be beneficial compared to a control/usual care group could be
used depending on clients’ preferences, lifestyle and values, health
professionals’ communication skills, and organisational context.
Implications for research
Evidence of the role of a healthy diet and/or specific nutrient intakes
on the prevention and management of chronic diseases is
well recognized. Further studies are now essential to refine methods
for providing dietary advice and improve diet adherence in the
context of chronic diseases. Several gaps in knowledge have been
identified in this review regarding the effectiveness of interventions
to enhance adherence to dietary advice for preventing and
managing chronic diseases in adults:
• Further good quality studies should be designed to
minimize bias and to have an adequate sample size to detect
significant differences between groups;
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 26
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
• Further studies with a long-term duration, namely more
than 12 months, and a follow-up evaluation are needed;
• Further research should be designed with a comparison
between an intervention group and a control/usual care group
both providing the same dietary advice to capture the effect of
the intervention only, without confounding factors;
• Further studies need to define clearly the term ’adherence’
and describe the intervention in detail. Moreover, there is a need
to develop standardized and validated self-report tools and
robust objective measures (e.g. biomarkers) to assess adherence
to dietary advice;
• Further studies should investigate the factors contributing
to clients’ non-adherence to dietary advice in order to develop
interventions to overcome barriers. These factors include
psychosocial and environmental determinants, but also
biological factors affecting food intake;
• Moreover, perspectives from health professionals and clients
about the interventions enhancing adherence to dietary advice
should be studied with the aim of identifying those that are most
implementable in practice and adaptable to local contexts
(Desroches 2011).
A C K N OWL E D G E M E N T S
We thank the staff and editors of the Cochrane Consumers and
Communication Review Group, especially Professor Adrian Edwards
(Contact Editor for this review), Dr Megan Prictor (Managing
Editor), Dr Sophie Hill (Coordinating Editor) andMr John
Kis-Rigo (Trials Search Coordinator). We also thank Dr Anik
Giguere for her assistance with systematic review methods, Jayne
Thirsk for her comments on the review and Narimane Toureche,
Sarah-Maude Deschênes, Catherine Laramée, Vincent Hao May,
Annabelle Fortier and Nadine Tremblay for their assistance with
the selection of studies and/or data extraction and/or tables conception.
Finally, we thank XiaoQiang Wang, Sumi Ross, Annette
Bluemle, Amélie Trépanier, Sonia Pomerleau, Claire Glenton and
Docent Suzana Nikolovska who assisted with translating publications
from languages other than English (Chinese, Japanese, German,
Spanish, Danish and Norwegian and Serbian).
R E F E R E N C E S
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HM, O’Brien WH. The relationship between selfmonitoring,
outcome expectancies, difficulties with eating
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Casebeer 1999 {published data only}
Casebeer LL, Klapow JC, Centor RM, Stafford MA,
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Cegala DJ, Marinelli T, Post D. The effects of patient
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Chlebowski RT, Blackburn GL, Buzzard IM, Rose DP,
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Darlington 1986 {published data only}
Darlington LG, Ramsey NW, Mansfield JR. Placebocontrolled,
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Del Corral P, Chandler-Laney PC, Casazza K, Gower BA,
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Dennis KE, Tomoyasu N, McCrone SH, Goldberg AP,
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comprehensive very-low-calorie diet program in obese
women with binge eating disorder. Behavior Therapy 2005:
89–99.
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Digenio AG, Mancuso JP, Gerber RA, Dvorak RV.
Comparison of methods for delivering a lifestyle
modification program for obese patients: a randomized
trial. Annals of Internal Medicine 2009;150:255–62.
Domenech 1995 {published data only}
Domenech MI, Assad D, Mazzei ME, Kronsbein P,
Gagliardino JJ. Evaluation of the effectiveness of an
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Donnelly JE, Kirk EP, Jacobsen DJ, Hill JO, Sullivan DK,
Johnson SL. Effects of 16 mo of verified, supervised aerobic
exercise on macronutrient intake in overweight men and
women: the Midwest Exercise Trial. American Journal of
Clinical Nutrition 2003;78:950–6.
Dyson 1997 {published data only}
Dyson PA, Hammersley MS, Morris RJ, Holman RR,
Turner RC. The Fasting Hyperglycaemia Study: II.
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advice in subjects with increased but not diabetic fasting
plasma glucose. Metabolism 1997;46:50–5.
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Evers SE, Bass M, Donner A, McWhinney IR. Lack of
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Farmer AJ, Wade AN, French DP, Simon J, Yudkin P, Gray
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Fehily 1991 {published data only}
Fehily AM, Vaughan-Williams E, Shiels K, Williams AH,
Horner M, Bingham G. Factors influencing compliance
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(DART). Journal of Human Nutrition and Dietetics 1991:
33–42.
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Ferrante D, Varini S, Macchia A, Soifer S, Badra R, Nul D,
et al. Long-term results after a telephone intervention in
chronic heart failure: DIAL (Randomized Trial of Phone
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Fitzgibbon ML, Stolley MR, Schiffer L, Sanchez-Johnsen
LA, Wells AM, Dyer A. A combined breast health/weight
loss intervention for Black women. Preventive Medicine
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Forget D, Caranhac G, Quillot MJ, Besnier MO.
Compliance with very low protein diet and ketoanalogues
in chronic renal failure. The French Multicentric Trial
IRCCA. Contributions to Nephrology 1990;81:79–86.
Forli 2001 {published data only}
Forli L, Bjortuft O, Vatn M, Kofstad J, Boe J. A study of
intensified dietary support in underweight candidates for
lung transplantation. Annals of Nutrition and Metabolism
2001;45:159–68.
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Forrester DL, Britton J, Lewis SA, Pogson Z, Antoniak M,
Pacey SJ, et al. Impact of adopting low sodium diet on
biomarkers of inflammation and coagulation: a randomised
controlled trial. Journal of Nephrology 2010;23:49–54.
Fox 1996 {published data only}
Fox AA, Thompson JL, Butterfield GE, Gylfadottir U,
Moynihan S, Spiller G. Effects of diet and exercise on
common cardiovascular disease risk factors in moderately
obese older women. The American Journal of Clinical
Nutrition 1996;63:225–33.
Frohling 1990 {published data only}
Frohling PT, Kaschube I, Vetter K, Knabich E, Lindenau
K, Schmicker R. Dietary compliance in the GDR trial.
Contributions to Nephrology 1990;81:87–94.
Frost 2007 {published data only}
Frost G, Masters K, King C, Kelly M, Hasan U, Heavens
P, et al. A new method of energy prescription to improve
weight loss. Journal of Human and Dietetics 2007;20:152–6.
Fuchs 1993 {published data only}
Fuchs Z, Viskoper JR, Drexler I, Nitzan H, Lubin F, Berlin
S, et al. Comprehensive individualised nonpharmacological
treatment programme for hypertension in physician-nurse
clinics: two year follow-up. Journal of Human Hypertension
1993;7:585–91.
Glasgow 2003 {published data only}
Glasgow RE, Boles SM, McKay HG, Feil EG, Barrera M
Jr. The D-Net diabetes self-management program: longterm
implementation, outcomes, and generalization results.
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Gorin A, Raynor H, Fava J, Maguire K, Robichaud E,
Trautvetter J, Crane M, Wing RR. Randomized control
trial of a comprehensive home environment-focused weight
loss program for adults: 18 month results. Obesity Society
Annual Scientific Meeting. 2010:95–OR.
∗ Gorin AA, Raynor HA, Fava J, Maguire K, Robichaud
E, Trautvetter J, et al. Randomised controlled trial of a
comprehensive home environment-focused weight loss
program for adults. Health Psychology 2012;Feb 6:E pub
ahead of print. [DOI: 10.1037/a0026959
Grancelli 2003 {published data only}
Grancelli H, Varini S, Ferrante D, Schwartzman R,
Zambrano C, Soifer S, et al. Randomized Trial of Telephone
Intervention in Chronic Heart Failure (DIAL): study design
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and preliminary observations. Journal of Cardiac Failure
2003;9:172–9.
Greene 1977 {published data only}
Greene LR. Effects of verbal evaluation feedback and
interpersonal distance on behavioral compliance. Journal of
Counseling Psychology 1977;24:10–4.
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Hakala P, Karvetti RL, Ronnemaa T. Group vs. individual
weight reduction programmes in the treatment of severe
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Hartwell SL, Kaplan RM, Wallace JP. Comparison of
behavioral interventions for control of Type II diabetes
mellitus. Behavior Therapy 1986;17:447–61.
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internet support on the long-term maintenance of weight
loss. Obesity Research 2004;12:320–9.
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Harvey Berino J, West D, Krukowski R, Prewitt E,
VanBiervliet A, Ashikaga T, et al. Internet delivered
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Hebert JR, Ebbeling CB, Olendzki BC, Hurley TG, Ma
Y, Saal N, et al. Change in women’s diet and body mass
following intensive intervention for early-stage breast
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Henkin 2000 {published data only}
Henkin Y, Shai I, Zuk R, Brickner D, Zuilli I, Neumann
L, et al. Dietary treatment of hypercholesterolemia: do
dietitians do it better? A randomized, controlled trial.
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Heraief 1985 {published data only}
Heraief E, Burckhardt P, Wurtman JJ, Wurtman RJ.
Tryptophan administration may enhance weight loss by
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Disorders 1985:281–92.
Hyman 1998 {published data only}
Hyman DJ, Ho KS, Dunn JK, Simons-Morton D. Dietary
intervention for cholesterol reduction in public clinic
patients. American Journal of Preventive Medicine 1998;15:
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Jolly K, Bradley F, Sharp S, Smith H, Mant D. Followup
care in general practice of patients with myocardial
infarction or angina pectoris: initial results of the SHIP
trial. Southampton Heart Integrated Care Project. Family
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Jolly K, Taylor R, Lip GY, Greenfield S, Raftery J,Mant J, et
al. The Birmingham Rehabilitation Uptake Maximisation
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Jula A, Ronnemaa T, Rastas M, Karvetti RL, Maki J. Longterm
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Kaiman DS, Colker CM, Swain MA, Torina GC, Shi Q. A
randomized, double-blind, placebo-controlled study of 3-
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Kalodner CR, DeLucia JL. The individual and combined
effects of cognitive therapy and nutrition education as
additions to a behavior modification program for weight
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Kalter-Leibovici 2010 {published data only}
Kalter-Leibovici O, Younis-Zeidan N, Atamna A, Lubin F,
Alpert G, Chetrit A, et al. Lifestyle intervention in obese
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Kattelmann KK, Conti K, Ren C. The medicine wheel
nutrition intervention: a diabetes education study with
the Cheyenne River Sioux Tribe. Journal of the American
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Khoo 2007 {published data only}
Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook
IA. A prospective randomized controlled trial of multimodal
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Kim 2006 {published data only}
Kim SH, Lee SJ, Kang ES, Kang S, Hur KY, Lee HJ, et al.
Effects of lifestyle modification on metabolic parameters
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Kirkman MS, Weinberger M, Landsman PB, Samsa GP,
Shortliffe EA, Simel DL, et al. A telephone-delivered
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Koelewijn-van Loon 2009 {published and unpublished data}
Koelewijn-van Loon MS, van der Weijden T, van Steenkiste
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Korhonen 1983 {published data only}
Korhonen T, Huttunen JK, Aro A, Hentinen M, Ihalainen
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Korhonen 2003 {published data only}
Korhonen M, KastarinenM, UusitupaM, Puska P, Nissinen
A. The effect of intensified diet counseling on the diet of
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education on glucose control. Journal of the Louisiana State
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Kumanyika SK, Hebert PR, Cutler JA, Lasser VI, Sugars
CP, Steffen-Batey L, et al. Feasibility and efficacy of sodium
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JD Jr, Bassett DR. Comparative effects of physical training
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Laws 2004 {published data only}
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management in primary care: the Counterweight
Programme. Journal of Human Nutrition and Dietetics
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Leermakers EA, Perri MG, Shigaki CL, Fuller PR. Effects
of exercise-focused versus weight-focused maintenance
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Lesley M L. Social problem solving training for African
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Lindahl B, Nilssön TK, Borch-Johnsen K, Røder ME,
Söderberg S, Widman L, et al. A randomized lifestyle
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Lopez Cabezas C, Falces Salvador C, Cubi Quadrada
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McCarron DA, Oparil S, Resnick LM, Chait A, Haynes
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McConnon A, Kirk SF, Cockroft JE, Harvey EL,
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Melchionda N, Forlani G, La Rovere L, Argnani P, Trevisani
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Melin I, Karlstrom B, Lappalainen R, Berglund L, Mohsen
R, Vessby B. A programme of behaviour modification
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Metz JA, Kris-Etherton PM, Morris CD, Mustad VA, Stern
JS, Oparil S, et al. Dietary compliance and cardiovascular
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Metz 2000 {published data only}
Metz JA, Stern JS, Kris-Etherton P, Reusser ME, Morris
CD, Hatton DC, et al. A randomized trial of improved
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Milas NC, Nowalk MP, Akpele L, Castaldo L, Coyne T,
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choices following a glycemic load intervention in adults
with type 2 diabetes. Journal of the American Dietetic
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Morgan PJ, Lubans DR, Collins CE, Warren JM, Callister
R. The SHED-IT randomized controlled trial: evaluation
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Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould
KL, Merritt TA, et al. Intensive lifestyle changes for reversal
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Pater C, Ditlef Jacobsen C, Rollag A, Sandvik L, Erikssen
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Pierce JP, Faerber S, Wright FA, Rock CL, Newman V,
Flatt SW, et al. A randomized trial of the effect of a plantbased
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Rimmer 2000 {published data only}
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Rosman JB, Langer K, Brandl M, Piers-Becht TP, van der
Hem GK, ter Wee PM, et al. Protein-restricted diets in
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Rosman JB, Donker-Willenborg MA. Dietary compliance
and its assessment in the Groningen trial on protein
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D, Roller S, et al. Diabetes management in a health
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Sartorio A, Lafortuna CL, Marinone PG, Tavani A, La
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G. Beyond good intentions: The role of proactive coping
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∗ Indicates the major publication for the study
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 42
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Aldarondo 1999
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: not known
Country: United States
Chronic disease: obesity (management)
Type of participants: clients (n = 43)
Mean age: intervention and control groups (44)
Sex: intervention and control groups (F: 86%, M: 14%)
Ethnicity: intervention and control groups (37 White, 3 African American, 1 Latino-
Hispanique, 1 Native-American, 1 Asian American)
Interventions Group 1: single intervention: enablement (behaviour change techniques: barrier identification/
problem solving, self-talk); 14 weeks; (n = 22)
Bi-weekly, the intervention took place in small groups during which clients talked about
their specific problems and concerns and created their problem-solving self-instructions
with the help of the group and the therapist. Homework assignments were given to
clients to apply problem-solving self-instruction form regarding eating
Group 2: control (unstructured support group); 14 weeks; (n = 21)
Outcomes Measurement of diet adherence: adherence to energy, fat and saturated fat intakes assessed
by a three-day food record (baseline, 14 weeks)
Notes Dietary advice: energy and fat-restricted diet
Drop-out rate: 0% (calculated)
Providers: doctoral students in counselling psychology
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Randomization was carried out by drawing
names from a hat”
Allocation concealment (selection bias) High risk “Randomization was carried out by drawing
names from a hat”
Blinding (performance bias and detection
bias)
Participants
Low risk “During the orientation meeting participants
were given detailed information
about the study except for the fact that
there would be more than one type of
’healthy lifestyle group’ (the CBT group
and the control group) with no further de-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 43
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Aldarondo 1999 (Continued)
tails given”
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data.
Selective reporting (reporting bias) High risk No protocol. Some outcomes are reported
incompletely (diet adherence, weight)
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Arcand 2005
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting: outpatient
Country: Canada
Chronic disease: heart failure (management)
Type of participants: clients (n = 50)
Mean age: intervention (56 ± 3), usual care (61 ± 3)
Sex: intervention (F: 28%, M: 72%) and usual care (F: 32%, M: 68%)
Ethnicity: not known
Interventions Group 1: multiple intervention: individual session with a dietitian + goal setting; 3
months; (n = 25)
An individualized nutrition care plans and goals were developed during a first counselling
session with a dietitian and a second counseling session occurred 4 to 6 weeks later
Group 2: usual care (no goal setting and no follow-up counselling session); once; (n =
25)
Outcomes Measurement of diet adherence: adherence to sodium-restricted diet assessed by a threeday
food record (baseline, 3 months)
Notes Dietary advice: sodium-restricted diet (2 g/day)
Drop-out rate: 6% (calculated)
Providers: intervention: dietitian; usual care: clinic nurse
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 44
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Arcand 2005 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation using a computer random
number generator
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk Plausible effect size among missing outcomes
not enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Assuncao 2010
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting : outpatient
Country : Brazil
Chronic disease: overweight and obesity (prevention/management)
Type of participants: clients (n = 241)
Mean age: intervention (41.1), usual care (39.6)
Sex: intervention (F: 90%, M: 10%) and usual care (F: 87.6%, M: 12.4%)
Ethnicity: intervention (82.5% White, 17.5 % non-White), usual care (87.6% White,
12.4% non-White)
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 45
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Assuncao 2010 (Continued)
Interventions Group 1: single intervention: modelling (nutritional tools); 6 months; (n = 120)
A manual was provided to clients containing photographs illustrating the portion sizes
of the prescribed foods in addition to nutritionally balanced food lists, with calorically
equivalent alternatives, in 100-cal portions. During monthly follow-up sessions, additional
explanations were provided regarding the menu and alternative foods
Group 2: usual care (no nutritional tools); 6 months; (n = 121)
Outcomes Measurement of diet adherence: adherence to advice regarding total energy, protein, fat,
carbohydrate, cholesterol, fiber, sodium, fruit, vegetable and sweet food intakes assessed
by a weekly food consumption questionnaire (baseline, 6 months)
Notes Dietary advice: energy controlled diet, 15 to 30% of energy from total fat; 55 to 75% of
energy from total carbohydrate; 10 to 15% of energy from protein; up to 300 mg/day
of cholesterol; up to 5 g/day of salt; up to 25 g/day of fiber; at least 400 g/day of fruit
and vegetables
Drop-out rate: 20.3% (calculated)
Providers: dietitians
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation referring to a random
number table.
Allocation concealment (selection bias) Low risk Allocation concealment using sequentially
numbered, opaque, sealed envelopes
Blinding (performance bias and detection
bias)
Participants
High risk “An unblind, randomised, controlled clinical
trial was (…)”
Blinding (performance bias and detection
bias)
Providers
High risk “An unblind, randomised, controlled clinical
trial was (…)”
Blinding (performance bias and detection
bias)
Outcome assessors
High risk “Except for laboratory tests, all other outcome
indicators were assessed by observers
that were unblind of the status of the study
participants”
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) High risk No protocol.Diet adherence is reported incompletely.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 46
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Assuncao 2010 (Continued)
Other bias High risk Baseline imbalance between groups (fasting
glucose). Diet adherence is assessed by selfreportedmeasure
(validated food frequency
questionnaire)
Baraz 2010
Methods Study design: randomized controlled trial with two intervention groups
Participants Setting: outpatient
Country: Iran
Chronic disease: chronic end-stage renal disease (management)
Type of participants: clients (n = 63)
Mean age: intervention group 1 (35.9 ± 10.1), intervention group 2 (33.8 ± 8.9)
Sex: intervention group 1 (F: 46.9%, M: 53.1%) and intervention group 2 (F: 48.4%,
M: 51.6%)
Ethnicity: intervention groups (100% Asian)
Interventions Group 1: multiple intervention: group session + educational tools-booklet; 2 weeks; (n
= 32)
Clients attended two educational sessions. An interactive portion of teaching program
was held at the end of class and clients were encouraged to offer support to each other.
Clients also received a teaching booklet to take home
Group 2: single intervention: education (educational tools-video); 1 week; (n = 31)
An educational film on a video disc system was shown to each client during two consecutive
dialysis sessions in a week
Outcomes Measurement of diet adherence: adherence to dietary restriction assessed by bimonthly
average values of serum sodium, potassium, calcium, phosphate, albumin, creatinine,
uric acid and blood urea nitrogen (baseline, 2 months); adherence to fluid-restricted
diet assessed by bimonthly interdialytic weight gain (baseline, 2 months)
Notes Dietary advice: 55 g/day of oil; 1.2 to 1.5 g/kg/day of protein; 2 g/day of sodium; 0.5
to 2 g/day of potassium; 1 g/day of phosphorus; restricted water intake (output 24h +
10 ml/kg/day)
Drop-out rate: 0% (calculated)
Provider: renal nurse expert
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “The random allocation was performed using
computer-generated random numbers
from 0 to 99.”
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 47
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Baraz 2010 (Continued)
Allocation concealment (selection bias) High risk “For an equal allocation to the two groups,
we took odd numbers to indicate group 1
(oral education) and even numbers to indicate
group 2 (video education).”
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data.
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed by
objective measures
Beasley 2008
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: research center
Country: United States
Chronic disease: overweight and obesity (prevention/management)
Type of participants: clients (n = 174)
Mean age: intervention (52 ± 12), control (54 ± 10)
Sex: intervention (F: 83%, M: 17%) and control (F: 77%, M: 23%)
Ethnicity: intervention (85% Caucasian, 10% Black, 5 % Asian), control (83.3% Caucasian,
16.7% Black, 0% Asian)
Interventions Group 1: single intervention: training (feedback); 4 weeks; (n = 89)
Clients received a Palm Zire 21 loaded with the DietMatePro program that displayed
personalized target values for energy based on the Harris-Benedict calculation using
National Institutes of Health (NIH) guidelines for weight loss as well as fat, saturated fat,
and cholesterol goals based on Ornish Prevention Diet recommendations. Additional
DietMatePro program features to assist in adhering to the dietary regimen included
feedback of comparisons between actual and target intake by meal and by day as well as
recipes and meal plans consistent with the assigned diet
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 48
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Beasley 2008 (Continued)
Group 2: control (no feedback); 4 weeks; (n = 85).
Outcomes Measurement of diet adherence: adherence to energy, fat, saturated fat and cholesterol
intakes assessed by a three-day DietMatePro (intervention) or paper-based (control) food
diaries and 24-hr recall (4 weeks)
Notes Dietary advice: Ornish Diet (individualized target of energy level based on the Harris-
Benedict calculation using NIH guidelines for weight loss, 10 to 15% of energy from
fat, up to 7% of energy from saturated fat and cholesterol less than 200 mg/day)
Drop-out rate: 8.6% (calculated)
Provider: research assistant
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Participants were then randomly assigned
to receive either the DietMatePro program
or the paper-based food diary as their food
recording method based on a randomization
table generated by the first author.”
Allocation concealment (selection bias) High risk Allocation concealment using an open random
allocation schedule (list of random
numbers)
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
High risk “Research assistants were aware of the participant’s
randomization assignment during
the assessment.”
Incomplete outcome data (attrition bias)
All outcomes
High risk The proportion of missing outcomes compared
with observed risk enough to induce
clinically relevant bias in intervention effect
estimate
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias High risk Baseline imbalance between groups (body
mass index). Diet adherence is assessed by
self-reported measures. Validation of Diet-
MatePro diary with paper based diary is re-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 49
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Beasley 2008 (Continued)
ported. Potential conflict of interest (“All
authors were employed at PICS at the time
of the study and PICS is the developer of
DietMatePro”)
Becker 1998
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting: outpatient
Country: United States
Chronic disease: risk of coronary heart disease (prevention)
Type of participants: clients (n = 156)
Mean age: intervention (46.1 ± 7.7), usual care (46.9 ± 6.8)
Sex: intervention (F: 47.6%, M: 52.4%) and usual care (F: 51.4%, M: 48.6%)
Ethnicity: not known
Interventions Group 1: multiple intervention: telephone follow-up + barrier identification/problem
solving; 2 years; (n = 84)
Meetings took place every four months and telephone calls occurred three times a year
for lipid therapy compliance and dietary counselling. Barriers to implementation of
diet, pharmacotherapy, exercise and smoking cessation were discussed. Encounters used
standardized prompts that centered on readiness to change, support systems, and the
sociocultural, work, and economic environment.
Group 2: usual care; duration not known; (n = 72)
Outcomes Measurement of diet adherence: adherence to fat-restricted diet assessed by the Block
Health Habits and History Questionnaire food frequency instrument (2 years)
Notes Dietary advice: consumption of less than 30% of total energy from fat and less than 300
mg/day of cholesterol
Drop-out rate: 23%
Providers: nurses and physicians
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Randomization was done by family using
a computerized schema”
Allocation concealment (selection bias) Unclear risk “Each family had a number with a corresponding
sealed envelope containing the
assignment. The envelopes were opened after
all siblings from the same family had
been screened.”
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Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Becker 1998 (Continued)
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Imbalance in numbers of missing data between
groups and the proportion ofmissing
outcomes compared with observed event
risk enough to induce clinically-relevant
bias in intervention effect estimate
Selective reporting (reporting bias) High risk No protocol. Some outcomes are reported
incompletely (weight, total cholesterol,
smoking, physical activity and blood pressure)
Other bias High risk Baseline imbalance between groups (HDLcholesterol).
Diet adherence is assessed by
self-reported measures (validated food frequency
questionnaire)
Bennett 1986
Methods Study design: randomized controlled trial with three intervention groups
Participants Setting: not known
Country: United Kingdom
Chronic disease: overweight and obesity (prevention/management)
Type of participants: clients (n = 53)
Mean age: intervention groups (40)
Sex: intervention groups (F: 100%)
Ethnicity: intervention groups (100% White)
Interventions Group 1: single intervention: enablement (behaviour change techniques: teach to use
prompts/cues); 16 weeks; (n = 18)
The aim was to reduce exposure to food cues by discussion of changes to make in food
storage habits and common target problem. Each session (weeks 5, 6, 7, 8, 9, 11 and
15) followed the same format: a brief review of recent dieting efforts; a central lesson
giving specific detailed advice on ways of reducing contact with food and one area of food
management; a discussion of a specific problem from the point of view of the program
as practice in problem solving and a summary of the content of the session.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 51
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Bennett 1986 (Continued)
Group 2: single intervention: enablement (behaviour change techniques: self-talk); 16
weeks; (n = 16)
The aim was to resist overeating by practising self-talk. Each session (weeks 5, 6, 7, 8, 9,
11 and 15) followed the same format: a brief review of recent efforts, a long period of
imaginal rehearsal and a summary of the content of the session.
Group 3: single intervention: enablement (behaviour change techniques: barrier identification/
problem solving); 16 weeks; (n = 19)
The aim was to improve self-control ability by reviewing problems encountered and
discussing about adherence to diet
Outcomes Measurement of diet adherence: adherence to energy intake assessed by a daily record
(baseline – 3 weeks – 6 weeks – 9 weeks – 12 weeks – 15 weeks)
Notes Dietary advice: specific quotas of exchanges, representing 1000 kCal below expected
energy requirements, with a minimum of 1000 kCal
Drop-out rate: 24.5% (calculated)
Providers: psychologist and dietitian
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation referring to a random
number table.
Allocation concealment (selection bias) High risk Allocation concealment using an open random
allocation schedule (list of random
numbers)
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 52
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Bennett 1986 (Continued)
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Blanson 2009
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: research center
Country: Netherlands
Chronic disease: overweight (prevention)
Type of participants: clients (n = 191)
Mean age: intervention (44.3 ± 12.2), control (43.0 ± 11.3)
Sex: intervention (F: 76.9%, M: 23.1%) and control (F: 88.7%, M: 11.3%)
Ethnicity: not known
Interventions Group 1: multiple intervention: motivational interviewing + feedback; 4 weeks; (n = 97)
A computer assistant represented by an animated iCat showed different facial expressions
and provided cooperative feedback following principles fromthemotivational interviewing
method.
Group 2: control (no computer assistant); 4 weeks; (n = 94)
Outcomes Measurement of diet adherence: adherence to diet goals assessed by a diary (28 days)
Notes Dietary advice: one of the following goals: 20 to 35% of energy from fat; at least two
pieces of fruit and 150 to 200 grams of vegetables/day; eat regularly (breakfast, lunch
and dinner and a maximum of two in between snacks)
Drop-out rate: 81.7% (calculated)
Provider: none
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Low risk “The participants were not aware there
were two groups”
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 53
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Blanson 2009 (Continued)
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed by
self-reported measure. Validation and reliability
of self-reported diet adherence are
not reported
Chen 2006
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: China
Chronic disease: renal failure (management)
Type of participants: clients (n = 70)
Mean age: intervention (57.6 ± 14.2), control (52.9 ± 14.9)
Sex: intervention (F: 57.1%, M: 42.9%) and control (F: 48.6%, M: 51.4%)
Ethnicity: not known
Interventions Group 1: single intervention: modelling (nutritional tools); duration not known; (n =
35)
Clients received an individualizedmenu suggestion based on food preferences and learned
how to make food substitution using an exchange list and portion-sized food aids.
Group 2: control (no menu suggestion); duration not known; (n = 35)
Outcomes Measurement of diet adherence: adherence to protein intake assessed by a three-day food
record (baseline, 1 month)
Notes Dietary advice: daily protein intake level 0.8 to 1.2 g/kg/day
Drop-out rate: 0% (calculated)
Provider: dietitian
Risk of bias
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 54
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Chen 2006 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “(…) all patients were then randomly assigned
to 1 of 2 groups using randomnumbers”
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data.
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Chiu 2010
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: China
Chronic disease: hypertension (management)
Type of participants: clients (n = 63)
Mean age: intervention (53.3 ± 7.8), control (54.4 ± 7.6)
Sex: intervention (F: 77.4%, M: 22.6%) and control (F: 56.2%, M: 43.8%)
Ethnicity: not known
Interventions Group 1: single intervention: education (telephone follow-up); 8 weeks; (n = 31)
A nurse performed a telephone follow-up every two to three weeks during which she
reinforced health self-management behaviours, providing health advice and assessed the
need for referrals.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 55
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Chiu 2010 (Continued)
Group 2: control (no telephone follow-up); 8 weeks; (n = 32)
Outcomes Measurement of diet adherence: adherence to sodium-restricted diet, control of fat intake
and adequate fruit and vegetable consumption assessed by a score (baseline, 8 weeks)
Notes Dietary advice: sodium-restricted diet, fat, fruit and vegetable intakes
Drop-out rate: 1.6% (calculated)
Providers: nurses
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Patients (…) were randomised to the
study or control group using sets of computer-
generated random numbers”
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk The outcome assessors were blinded for the
satisfaction questionnaire but this study did
not address the blinding for other outcomes
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) Unclear risk No protocol
Other bias High risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure
(validated scale). An effect of intervener
could have influenced results
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 56
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Conrad 2000
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: Canada
Chronic disease: coronary artery disease (management)
Type of participants: clients (n = 7)
Mean age: not known
Sex: not known
Ethnicity: not known
Interventions Group 1: single intervention: restriction; 7 months; (n = 4)
INCREMENTAL REDUCTION OF FAT: Meal plan initially targeted intake of 26%
to 30% of energy as fat. At two months, patients were given meal plan targeting 20%
fat energy intake. Finally, at four months they were given meal plan targeting 10% fat
energy intake.
Group 2: control; 7 months; (n = 3)
IMMEDIATE REDUCTIONOF FAT: Meal plan consisted to an immediate reduction
of fat energy intake (10%). The meal plan was reinforced two and four months after the
program
Outcomes Measurement of diet adherence: adherence to very low fat diet assessed by a 24-hr recall
(7 months)
Notes Dietary advice: 10% of energy from fat
Drop-out rate: 0% (calculated)
Provider: dietitian
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 57
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Conrad 2000 (Continued)
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data.
Selective reporting (reporting bias) High risk No protocol. Diet adherence is not clearly
defined.
Other bias High risk Baseline comparisons between groups are
not reported. Diet adherence is not clearly
defined
Cummings 1981
Methods Study design: randomized controlled trial with three intervention groups and one control
group
Participants Setting: outpatient
Country: United States
Chronic disease: renal failure (management)
Type of participants: clients (n = 116)
Mean age: intervention and control groups (54.8)
Sex: intervention and control (F: 46%, M: 54%)
Ethnicity: intervention and control groups (50% White)
Interventions Group 1: single intervention: incentivisation (contract with reward); 6 weeks; (n = 29)
A behavioural contract was formulated and consisted of: identifying a behaviour or set
of behaviours to be targeted for change in the contract; negotiating with the client a
timetable for the accomplishment of the specified behaviours, how should the degree
of accomplishment be evaluated, what rewards would be received for appropriate behaviours,
when the client would be rewarded; writing out a formal agreement which
was subsequently signed by both the nurse and the client; maintaining a record of each
client’s progress.
Group 2: multiple intervention: Incentivisation (contract with reward) and persuasion
(involvement of a family member or friend) (n = 29)
A behavioural contract was formulated and consisted of: identifying a behaviour or set
of behaviours to be targeted for change in the contract; negotiating with the client a
timetable for the accomplishment of the specified behaviours, how should the degree
of accomplishment be evaluated, what rewards would be received for appropriate behaviours,
when the client would be rewarded; writing out a formal agreement which
was subsequently signed by both the nurse and the client; maintaining a record of each
client’s progress. Moreover, a third person selected by the patient participated in the
contract agreement along with the patient and the nurse.
Group 3:single intervention: education (telephone follow-up); 6 weeks; (n = 29)
Weekly, clientswere contacted by telephone.Telephone follow-up consisted of: gathering
information from clients regarding problems they might be having in following their
treatment instructions; providing information to clients about such things as the potential
negative health consequences of not adhering to therapy, the benefits to be derived
from following treatment instructions, and things the clients could do to achieve better
compliance; providing verbal support to clients for maintaining proper adherence to
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 58
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Cummings 1981 (Continued)
treatment
Group 4: control (no contract or telephone follow-up); 6 weeks, (n = 29)
Outcomes Measurement of diet adherence: adherence to potassium-restricted diet and fluid-restricted
diet assessed by serum potassium level and weight gain between dialysis treatments
(baseline, 6 weeks, 3 months)
Notes Dietary advice: potassium-restricted diet and fluid-restricted diet
Drop-out rate: 25% (calculated)
Providers: nurses
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation using a computer random
number generator
Allocation concealment (selection bias) High risk Allocation concealment using case record
number.
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Low risk Baseline imbalance between groups but the
authors adjusted for initial group differences.
Diet adherence is assessed by objective
measures
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 59
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
French 2008
Methods Study design: randomized controlled trial with two intervention groups and one usual
care group
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: type II diabetes (management)
Type of participants: clients (n = 453)
Mean age: intervention and usual care groups (65.9 ± 10)
Sex: intervention and usual care groups (F: 41.3%, M: 58.7%)
Ethnicity: not known
Interventions Group 1: Single intervention: training (feedback); 1 year; (n = 150)
LESS INTENSIVE INTERVENTION: clients were asked to use a blood glucose meter
to record three fasting, pre-meal or two hour post meal readings on two days during the
week. Treatment targets of fasting and pre-meal levels were given
Group 2: Single intervention: training (feedback); 1 year; (n = 151)
MOST INTENSIVE INTERVENTION: clients were asked to use a blood glucose
meter to record three fasting, pre-meal or two hour postmeal readings on two days during
the week. Treatment targets of fasting and pre-meal levels were given and clients were
trained in interpretation of results. Clients were also asked to view persistently elevated
levels as a prompt to set new goals for behaviour change.
Group 3: usual care (no feedback); 1 year; (n = 152)
Outcomes Measurement of diet adherence: adherence to the general diet and the specific diet items
concerning fruit and vegetables as well as high-fat foods assessed by the Summary of
Diabetes Self-Care Activities (baseline, 12 months)
Notes Dietary advice: not known
Drop-out rate: 25.2%
Providers: nurses
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “(…) using a partial minimisation procedure
to adjust the randomisation probabilities
between groups to balance important
covariates (…) using a computer programme”
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 60
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French 2008 (Continued)
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Low risk Questionnaire responses were entered onto
computer by staff unaware of intervention
allocation
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) Low risk The study protocol is available and all of
the study’s pre-specified outcomes that are
of interest in the review have been reported
in the pre-specified way
Other bias High risk Baseline comparisons between groups are
not reported. Diet adherence is assessed
by self-reported measure (SDSCA). The
Cronbach’ s alpha for the Summary of Diabetes
Self-Care Activities (SDSCA) (specific
diet) was low 0.08
Gans 1994
Methods Study design: randomized controlled trial with three intervention groups and one usual
care group
Participants Setting: workplace and community
Country: United States
Chronic disease: elevated blood cholesterol (prevention)
Type of participants: clients (n = 173)
Mean age: intervention group 1 (51.1 ± 13.5), intervention group 2 (50.1 ± 17.5),
intervention group 3 (50.3 ± 14.6), usual care (53.9 ± 14.9)
Sex: intervention group 1 (F: 45.2%, M: 54.8%), intervention group 2 (F: 46.7%, M:
53.3%), intervention group 3 (F: 44.1%, M: 55.9%) and usual care (F: 44.4%, M: 55.
6%)
Ethnicity: intervention group 1 (95.1% White, 26.8% Portuguese), intervention group
2 (94.9% White, 15.4% Portuguese), intervention group 3 (100% White, 26.1% Portuguese),
usual care (95.6% White, 29.5% de Portuguese)
Interventions Group 1: single intervention: persuasion (reminder); once; (completers: n = 42)
Clients received a mailed personalized letter including their blood cholesterol level, a
reminder to see their physician, a list of the specific lifestyle goals, the subject set at
the community-based blood cholesterol Screening, Counseling, Referral Events (SCORE)
, and a Pawtucket Heart Health Program magnet for refrigerator.
Group 2: single intervention: persuasion (reminder); once; (completers: n = 39)
Physician received a mailed packet including a letter stating that their patient had been
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 61
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Gans 1994 (Continued)
referred on the basis of their blood cholesterol level and coronary heart disease risk
factors. There was a listing of the lifestyle goals the subject set at the SCORE, National
Cholesterol Education Program(NCEP) guidelines and a reminder postcard (preaddressed
to the client) which the physician could mail to the client.
Group 3: single intervention: persuasion (reminder); once; (completers: n = 47)
Clients received a mailed personalized letter including their blood cholesterol level, a
reminder to see their physician, a list of the specific lifestyle goals, the subject set at the
SCORE, and a Pawtucket Heart Health Program magnet for refrigerator. The physician
also received amailed packet including a letter setting that their patient had been referred
on the basis of their blood cholesterol level and coronary heart disease risk factors. There
was a listing of the lifestyle goals the subject set at the SCORE, NCEP guidelines and
a reminder postcard (preaddressed to the client) which the physician could mail to the
client.
Group 4: usual care (no reminder); once; (completers: n = 45)
Outcomes Measurement of diet adherence: adherence to dietary advice assessed by a telephone
questionnaire (baseline, 3 months)
Notes Dietary advice: not known
Drop-out rate: not known
Providers: physicians
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) Unclear risk No protocol.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 62
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Gans 1994 (Continued)
Other bias High risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported.The
time interval between SCORE and survey
varied between subject and could influenced
results
Gill 2010
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: research center
Country: United States
Chronic disease: overweight and obesity (prevention/management)
Type of participants: clients (n = 64)
Mean age: intervention (19.1 ± 1.0), control (19.1 ± 1.0)
Sex: intervention and control groups (F: 100%)
Ethnicity: intervention (70% White, 10% African American, 10% Latina/Hispanic,
10% Other), control (66% White, 17% African American, 14% Latina/Hispanic, 3%
Other)
Interventions Group 1: single intervention: education (group sessions); 8 weeks; (n = 32)
Participants attended a weekly education group sessions run by a dietitian and an exercise
physiologist.
Group 2: control (no education group sessions); 8 weeks; (n = 32)
Outcomes Measurement of diet adherence: adherence to Dietary Approaches to Stop Hypertension
(DASH) diet assessed by the DASH Diet Index (baseline, 8 weeks)
Notes Dietary advice: DASH diet and hypocaloric diet
Drop-out rate: not known
Providers: dietitian and exercise physiologist
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation using a computer random
number generator
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 63
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Gill 2010 (Continued)
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Unclear risk Baseline balance between groups not reported.
Diet adherence is assessed by selfreported
measure. Validation and reliability
of self-reported diet adherence are not
reported
Grace 1996
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: hyperlipidaemia (prevention)
Type of participants: clients (n = 13)
Mean age: not known
Sex: intervention group (F: 25%, M: 75%) and control group (F: 40%, M: 60%)
Ethnicity: intervention and control groups (100% Caucasian)
Interventions Group 1: single intervention: modelling (nutritional tools); once; (n = 8)
Clients received standard low-fat dietary advice with an additional package containing
details on improving the practical implementation of a low-fat diet, such as low-fat
cooking methods, low-fat recipe adaptation and eating out on a low-fat diet.
Group 2: control (standard dietary advice with no information package); duration: not
known; (n = 5)
Outcomes Measurement of diet adherence: adherence to total daily energy intake and proportion
of energy from fat assessed by a food-frequency questionnaire (baseline, 12 weeks)
Notes Dietary advice: low-fat diet
Drop-out rate: 0% (calculated)
Providers: not known
Risk of bias
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 64
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Grace 1996 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) High risk No protocol. Body mass index is reported
incompletely. Diet adherence is not clearly
defined
Other bias High risk Baseline imbalance between groups (% fat)
. Diet adherence is not clearly defined
Gucciardi 2007
Methods Study design: randomized controlled trial with one intervention and one control group
Participants Setting: outpatient
Country: Canada
Chronic disease: type II diabetes (management)
Type of participants: clients (n = 87)
Mean age: intervention (60.4 ± 7.9), control (59.0 ± 12.1)
Sex: intervention (F: 68%, M: 32%) and control (F: 69.4%, M: 30.6%)
Ethnicity: intervention and control groups (100% Portuguese)
Interventions Group 1: multiple intervention: group sessions + barrier identification/problem solving
+ nutritional tools; 3 months; (n = 41)
The education intervention lasted 15 hrs over three consecutive weekdays in which
didactic methods, mutual goal setting, situational problem solving, cognitive reframing
and role-playing methods were used. Some nutritional tools were provided such as food
models, kitchen demonstration, real food samples and food product labels.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 65
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Gucciardi 2007 (Continued)
Group 2: control; 3 months; (n = 46)
Clients met the dietitian individually.
Outcomes Measurement of diet adherence: adherence to dietary advice assessed by the Summary of
diabetes Self-care activities Questionnaire (baseline, 3 months)
Notes Dietary advice: based on an assessment of clients’ metabolic profile and on existing
comorbidities such as renal nephropathy or gastrointestinal complications: 1) a limited
and consistent intake of carbohydrates at each meal; 2) an adequate daily intake of fruit
and vegetables; 3) a lower intake of saturated fat; 4) a reduced fat in cooking
Drop-out rate: 29.9% (calculated)
Providers: dietitian, nurse, pharmacist, physiotherapist
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Participants were randomly assigned (generated
random number list)…”
Allocation concealment (selection bias) High risk Allocation concealment using an open random
allocation schedule (list of random
numbers)
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Low risk “DEC (Diabetes Education Centre)
providers were also blinded to patients’ research
participation status and were caring
for all the participants regardless of the intervention
assignment”
Blinding (performance bias and detection
bias)
Outcome assessors
Low risk “The research assistants were blinded to
participants’ intervention status.”
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Low risk Baseline balance between groups. Diet adherence
is assessed by self-reportedmeasure
(validated Summary of Diabetes Self-care
Activities Questionnaire)
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Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Hsueh 2007
Methods Study design: randomized controlled trial with two intervention groups
Participants Setting: research center
Country: United States
Chronic disease: irritable bowel syndrome (management)
Type of participants: clients (n = 81)
Mean age: intervention group 1 (45.8 ± 14.1), intervention group 2 (46.1 ± 14.5)
Sex: intervention group 1 (F: 82.1%, M: 17.9%) and intervention group 2 (F: 88.1%,
M: 11.9%)
Ethnicity: intervention group 1 (87.2% White, 0% African American, 5.1% Asian/
Indian, 7.7% Native American), intervention group 2 (83.3% White, 4.8% African
American, 9.5% Asian/Indian, 0% Native American, 2.4% Unknown)
Interventions Group 1: single intervention: education (individual sessions with a nurse); 9 weeks; (n
= not known)
The intervention included 9 hours of face-to-face sessions inwhich the nurse reviewed the
previous homework assignment and discussed howto individualize dietarymodifications.
Group 2: multiple intervention: individual sessions with a nurse + telephone follow-up;
9 weeks; (n = not known)
The intervention included two face-to-face sessions, six telephone sessions and one final
face-to-face session in which the nurse reviewed the previous homework assignment and
discussed how to individualize dietary modifications
Outcomes Measurement of diet adherence: adherence to American Dietetic Association recommendations
for fiber intake (more than 20 g/day) and Food Guide Pyramid for fruit intake
(more than 2 servings/day) and vegetable intake (more than 3 servings /day) assessed by
a food-frequency questionnaire (baseline, 3 months, 6 months)
Notes Dietary advice: individualized based on the symptoms: 25 g of fiber/day in constipationpredominant
and 20 g of fiber/day for diarrhoea-predominant
Drop-out rate: not known
Providers: research nurses
A usual care group was included in this study. Since no active treatment was provided in
the usual care group, this group was not described in the Cochrane review
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “(…) participants were randomly assigned
using a customized computer program(…)
”
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 67
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Hsueh 2007 (Continued)
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias High risk Baseline imbalance between groups (fiber,
vegetables and fruit). Diet adherence is assessed
by self-reported measure (validated
food frequency questionnaire)
Hyman 2007
Methods Study design: randomized controlled trial with two intervention groups and one usual
care group
Participants Setting: outpatient
Country: United States
Chronic disease: hypertension (management)
Type of participants: clients (n = 281)
Mean age: intervention group 1 (53.9 ± 5.7), intervention group 2 (53.4 ± 5.7), usual
care (52.7 ± 6.5)
Sex: intervention group 1 (F: 65.2%, M: 34.8%), intervention group 2 (F: 63.5%, M:
36.5%), usual care (F: 73.1%, M: 26.9%)
Ethnicity: intervention and usual care groups (100% African American)
Interventions Group 1: multiple intervention: telephone follow-up + motivational interviewing; 18
months; (n = 92)
SIMULTANEOUS BEHAVIOUR CHANGE: a brief in-clinic session with a health
educator was provided to clients every six months to review the benefits of the recommended
three behavioural changes (stop smoking, reduce dietary sodium level and increase
physical activity), the home-based, self-help (printed manual, motivational videotape),
instructional materials developed to facilitate behaviour change and the schedule
of telephone counselling session. All three behaviours were reviewed at each clinic session.
There were seven telephone follow-ups between each in-clinic session.
Group 2: multiple intervention: telephone follow-up + motivational interviewing; 18
months; (n = 96)
SEQUENTIAL BEHAVIOUR CHANGE: a brief in-clinic session with a health educator
was provided to clients every six months to review the benefits of the recommended
behavioural change (stop smoking, reduce dietary sodium level and increase physical
activity), the home-based, self-help (printed manual, motivational videotape), instruc-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 68
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Hyman 2007 (Continued)
tional materials developed to facilitate behaviour change and the schedule of telephone
counselling session. The protocol addressed a new behaviour every 6months. There were
seven motivational interviewing telephone follow-ups between each in-clinic session.
Group 3: usual care (no telephone follow-up); once; (n = 93)
Abrief reviewof educationalmaterialswas provided regarding the three targets behaviours
(stop smoking, reduce dietary sodium level and increase physical activity)
Outcomes Measurement of diet adherence: adherence to sodium-restricted diet assessed by 24-hr
urine sodium level <100mEq/l/day) (baseline, 6 months, 18 months)
Notes Dietary advice: sodium-restricted diet (less than 100 mEq/l/day (urinary))
Drop-out rate: 20.4%
Provider: health educator
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk The proportion of missing outcomes compared
with observed event risk enough to
have a clinically-relevant impact on the intervention
effect estimate
Selective reporting (reporting bias) High risk No protocol. Blood glucose is reported incompletely.
Other bias High risk Baseline imbalance between groups (diastolic
blood pressure). Diet adherence is assessed
by objective measure. The order in
which the behaviors were introduced to
each participant in the sequential groupwas
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 69
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Hyman 2007 (Continued)
randomized to avoid confounding of outcomes
with patient preferences
Jiang 2004
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting: outpatient
Country: China
Chronic disease: angina pectoris or myocardial infarction (management)
Type of participants: clients (n = 167)
Mean age: intervention (62.1 ± 7.4), usual care (61.4 ± 7.6)
Sex: intervention (F: 31.3%, M: 68.7%) and usual care (F: 26.2%, M: 73.8%)
Ethnicity: intervention and usual care groups (100% Chinese)
Interventions Group 1: multiple intervention: telephone follow-up + individual session with nurse +
goal setting; 12 weeks; (n = 83)
After discharge from the hospital, clients received a weekly home visit during the first
three weeks and alternating home visit and telephone follow-up every other week from
week 4 to 12. The cardiac rehabilitation program consisted of: setting of the goals for
walking performance, smoking cessation, Adult Treatment Panel step II (ATP step II) diet
adherence and medication adherence; setting of the goals for cardiac physiological risk
control; clients conducted a goal-directed self-managed rehabilitative care in medication
management, angina management, physical exercise, dietary management and smoking
cessation according to the recommended guidelines on a daily basis; keeping a log record
for tracking progress as well as for self-evaluation and self-reinforcement.
Group 2: usual care (no cardiac rehabilitation program); duration: not known; (n = 84)
Outcomes Measurement of diet adherence: adherence to ATP step II diet assessed by a 3-day food
record (baseline, 3 months, 6 months)
Notes Dietary advice: ATP step II diet (< 8% of total energy from saturated fat and < 250 mg/
d of cholesterol)
Drop-out rate: 15.6% (calculated)
Provider: cardiac nurse
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “(…) randomised assignment of subjects
into an intervention group and a control
group according to a computer-generalized
random table”
Allocation concealment (selection bias) Low risk Allocation concealment using central allocation.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 70
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Jiang 2004 (Continued)
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Low risk “They (research assistants) were blinded to
patient group assignment”
Incomplete outcome data (attrition bias)
All outcomes
High risk The proportion of missing outcomes compared
with observed event risk enough to
have a clinically-relevant impact on the intervention
effect estimate
Selective reporting (reporting bias) High risk No protocol. Smoking cessation is reported
incompletely.
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Jones 1986
Methods Study design: randomized controlled trial with four intervention groups
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: overweight (prevention)
Type of patients: clients (n = 80)
Mean age: intervention groups: 50.3 ± 13.5
Sex: intervention groups (F: 100%)
Ethnicity: not known
Interventions Group 1: single intervention: education (group sessions); 16 weeks; (n = 19)
Clients met the dietitian every four weeks in small groups of five to seven clients.
Group 2: multiple intervention: individual sessions with a dietitian + teach to use
prompts/cues; 16 weeks; (n = 20)
Clients saw the dietitian every four weeks individually. Clients were provided with one
set of leaflets on each of their first four visits. These provided specific detailed advice on
how to reduce their exposure to food cues by making a variety of changes in their habits,
and were based on the cue avoidance programme and the food management programme.
Group 3: multiple intervention: group sessions + teach to use prompts/cues; 16 weeks,
(n = 21)
Clients met the dietitian every four weeks in small groups of five to seven clients. Clients
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 71
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Jones 1986 (Continued)
were provided with one set of leaflets on each of their first four visits. These provided
specific detailed advice on how to reduce their exposure to food cues by making a variety
of changes in their habits, and were based on the cue avoidance programme and the food
management programme.
Group 4: single intervention: education (individual sessions with a dietitian); 16 weeks;
(n = 20)
Clients met the dietitian individually every four weeks.
Outcomes Measurement of diet adherence: adherence to the diet allowance assessed by a diary (16
weeks)
Notes Dietary advice: energy levels 1000 kCal below expected energy requirements, with a
minimum of 1000 kCal/day
Drop-out rate: not known
Providers: dietitians
Four additional groups were included in this study. Since the clients in these groups did
not complete a diary to assess adherence to dietary advice, these four groups were not
described in the Cochrane review
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 72
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Jones 1986 (Continued)
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed by
self-reported measure. Validation and reliability
of self-reported diet adherence are
not reported
Kendall 1987
Methods Study design: randomized controlled trial with two intervention groups
Participants Setting: outpatient
Country: United States
Chronic disease: non-insulin-dependent diabetes (management)
Type of participants: clients (n = 83)
Mean age: intervention group 1 (56.2 ± 16.0), intervention group 2 (60.2 ± 13.8)
Sex: intervention group 1 (F: 66.7%, M: 33.3%) and intervention group 2 (F: 70.7%,
M: 29.3%)
Ethnicity: not known
Interventions Group 1: single intervention: education (educational tools – booklet); 3 weeks; (completers:
n = 42)
Clients assisted to three workshops at one week intervals during which a Colorado State
UniversityDiet Guide for Planning Prudent Diet, worksheets for planning and evaluating
menus, leader’s guide, and three slide-cassette tape programs on diabetes, using the diet
guide and expanding the diet guide were provided.
Group 2: single intervention: modelling (nutritional tools); 3 weeks; (completers: n =
41)
Clients assisted to three workshops at one week intervals during which the exchange lists
for meal planning was provided and used as the menu planning and evaluation tool. A
slide-cassette tape program was also used to help teach the exchange lists
Outcomes Measurement of diet adherence: adherence to Recommended Dietary Allowances of the
Food and Nutrition Board (energy, protein, vitamins (A, C, thiamine, riboflavin, niacin),
and minerals (calcium, phosphorus, iron and zinc)) assessed by a three-day food record
(baseline, 3 months, 6 months)
Notes Dietary advice: prudent diet
Drop-out rate: not known
Providers: dietitian and senior author
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation referring to a random
number table.
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Kendall 1987 (Continued)
Allocation concealment (selection bias) High risk Allocation concealment using an open random
allocation schedule
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Low risk “Food records were reviewed and blind
coded for computer processing and analysis
so that data analyzers were not aware of
treatment group”
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) High risk No protocol. Diet adherence is not clearly
defined.
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Laitinen 1993
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting: outpatient
Country: Finland
Chronic disease: non-insulin-dependent diabetes (management)
Type of participants: clients (n = 86)
Mean age: intervention (F: 53.7 ± 6.3, M: 50.7 ± 7.7), usual care (F: 54.4 ± 6.4, M: 54.
0 ± 6.6)
Sex: intervention (F: 47.5%, M: 52.5%) and usual care (F: 39.1%, M: 60.9%)
Ethnicity: intervention and usual care groups (100% white)
Interventions Group 1: multiple intervention: individual session with a dietitian + nutritional tools +
goal setting; 12 months; (n = 40)
During each bimonthly visits, the clinical dietitians and the client set one or two clear
short-termgoals for dietary change and a goal for weight loss. A food preparation practice
was also provided.
Group 2: usual care; duration: not known; (n = 46)
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 74
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Laitinen 1993 (Continued)
Outcomes Measurement of diet adherence: adherence to total fat, saturated fat, unsaturated fat,
carbohydrates, fiber and cholesterol intake assessed by a three-day food record (baseline,
3 months, 15 months)
Notes Dietary advice: restricted energy, fat (especially saturated fatty acid) and dietary cholesterol
intakes, increased unsaturated fatty acid and unrefined carbohydrate intakes and
avoided large amounts of simple carbohydrates
Drop-out rate: 0% (calculated)
Providers: intervention: physician, nurse and clinical dietitian; usual care: physician and
nurse
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation referring to a random
number table.
Allocation concealment (selection bias) Low risk Allocation concealment using sequentially
numbered, opaque, sealed envelopes
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk The proportion of missing outcomes compared
with observed risk enough to induce
clinically-relevant bias in intervention effect
estimate
Selective reporting (reporting bias) High risk No protocol.Diet adherence is reported incompletely.
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed by
self-reported measure. Validation and reliability
of self-reported diet adherence are
not reported
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 75
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Logan 2010
Methods Study design: randomized controlled trial with two intervention groups
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: coronary heart disease (management)
Type of participants: clients (n = 40)
Mean age: intervention group 1 (57.7 ± 7.8), intervention group 2 (58.0 ± 9.2)
Sex: intervention group 1 (F: 19%, M: 81%) and intervention group 2 (F: 15.8%, M:
84.2%)
Ethnicity: not known
Interventions Group 1: single intervention: modelling (nutritional tools); 4 months; (n = 21)
Clients received detailed information regarding the implementation of the Mediterranean
diet and were provided with a diet sheet, which contained detailed advice and
information on the Mediterranean diet, the potential health benefits of the diet, recipe
ideas and a samplemeal plan. Then, they received a home visit fromthe dietitian at week
one and at months one, two and four.
Group 2: single intervention: enablement (behavior change techniques: barrier identification/
problem solving, goal setting); 4 months; (n = 19)
Interventions were tailored to the individual, with personal specific advice and setting
of short-and long-term goals based on their stage of change measure, which reflected
their readiness to adopt a Mediterranean diet. Clients were provided a diet sheet and
also a Help to change booklet, which contained a list of the common difficulties found
when making dietary change, as well as suggestions for overcoming these. They received
a home visit from the dietitian at week one and at months one, two and four
Outcomes Measurement of diet adherence: adherence toMediterranean diet assessed by a validated
questionnaire (baseline, 6 months, 12 months)
Notes Dietary advice: seven to ten portions of fruit and vegetables/day,morewhole grain cereals,
more fish (four portions/week), less meat (approximately once/week), and butter and
cream were replaced with an olive-oil based spread. The oils recommended for salads
and food preparation were olive and rapeseed oils. Moderate alcohol consumption, in
the form of wine, was allowed at meals. Patients were also advised to include unsalted
nuts as snacks
Drop-out rate: 15.5%
Provider: dietitian
A usual care group was included in this study. Since the Mediterranean diet was not
provided in the usual care group, this group was not described in the Cochrane review
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Willing participants (n = 61) were randomised
(using a block randomisation approach
with computer generated random
numbers) …”
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 76
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Logan 2010 (Continued)
Allocation concealment (selection bias) High risk Allocation concealment using an open random
allocation schedule (list of random
numbers)
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Low risk Baseline balance between groups. Diet adherence
is assessed by self-reportedmeasure
(validated questionnaire)
Mahler 1999
Methods Study design: randomized controlled trial with two intervention groups and one control
group
Participants Setting: outpatient
Country: United States
Chronic disease: coronary artery disease (management)
Type of participants: clients (n = 215)
Mean age: intervention group 1 (59.7 ± 8.5), intervention group 2: (63.1 ± 7.7), control
(61.1 ± 8.7)
Sex: intervention group 1 (F: 14%, M: 86%), intervention group 2 (F: 11%, M: 89%)
and control (F: 16%, M: 84%)
Ethnicity: intervention group 1 (81.5% White, 1.5% Asian, 13.8% Hispanic, 1.5%
African American, 1.5% Other), intervention group 2 (82.7%White, 4%Asian, 10.7%
Hispanic, 2.7%African American), control (85.3% White, 4%Asian, 10.7% Hispanic)
Interventions Group 1: single intervention: education (educational tools – video); once; (n = 65)
Mastery tape was made to depict these clients as calmand confident at the time of release,
as making steady progress with no mention of complications during the six months after
surgery, and as adjusting to the recommended exercise and low-fat diet with relative ease.
Group 2: multiple intervention: educational tools- video + relapse prevention/coping
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 77
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Mahler 1999 (Continued)
planning; once; (n = 75)
Coping tape was edited so that the same clients mention concerns they are experiencing
about hospital release and cope with effort but successfully with a variety of difficulties
(e.g. heart rhythm disturbances, fatigue, diet changes)
Group 3:control (no video); once; (n = 75)
Outcomes Measurement of diet adherence: adherence to cholesterol and saturated fat-restricted diet
assessed by the cholesterol-saturated fat subscale of the Diet Habit Survey (1 month – 3
months)
Notes Dietary advice: low-cholesterol and low-fat diet
Drop-out rate: 9%
Provider: cardiothoracic nurse specialist
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation referring to a random
number table.
Allocation concealment (selection bias) Low risk Allocation concealment using sequentially
numbered, opaque, sealed envelopes
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed
by self-reported measure (validated Diet
Habit Survey)
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 78
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
McCulloch 1983
Methods Study design: randomized controlled trial with two intervention groups and one usual
care group
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: insulin dependent diabetes (management)
Type of participants: clients (n = 40)
Mean age: intervention group 1 (31.6 ± 8.3), intervention group 2 (36.5 ± 15.3), usual
care (35.6 ± 10.4)
Sex: intervention group 1 (F: 38.5%, M: 61.5%), intervention group 2 (F: 46.2%, M:
53.8%) and usual care (F: 42.9%, M: 57.1%)
Ethnicity: not known
Interventions Group 1: single intervention: modelling (nutritional tools); 6 months; (n = 13)
Clients had individual assessment, dietary pamphlet containing 10 g carbohydrate exchange
lists and were asked to come three times to the hospital canteen in groups of four
or five where they had lunch with both dietitian and doctor. Participants were asked to
help themselves to a variety of hot and cold dishes and to make up their carbohydrate
allowance to what had been prescribed for them previously. After lunch they were shown
a display of other items of food so that they could see and feel exactly how much of each
item did in fact contain 10 g carbohydrate.
Group 2: single intervention: education (education tools – video); 6 months; (n = 13)
Clients had individual assessment and a dietary pamphlet containing 10 g carbohydrate
exchange lists and viewed a 24 minutes videotape. This was viewed on three separate
occasions while sitting in an armchair in a quiet room, and without dietitian or doctor
being present. The videotape began with an explanation of the importance of eating a
balanced diet and maintaining a consistent carbohydrate profile. It then took the viewer
through a day in the life of two insulin treated patients with very different dietary
requirements and lifestyles. It ended by suggesting that the viewer should try to work
out his or her own carbohydrate profile with the dietitian’s help.
Group 3: usual care: no lunchtime nor video; 6 months; (n = 14)
Clients were assessed by a dietitian and received individual instructions about what carbohydrate
distribution would be appropriate for them. In addition to a pamphlet containing
10 g exchange lists they were given simple menus to emphasize the carbohydrate
profile they should stick to from day to day. Clients were seen for dietary instruction
three times
Outcomes Measurement of diet adherence: adherence to day to day consistency in carbohydrate
intake assessed by a seven-day food record (baseline, 6 months)
Notes Dietary advice: an appropriate total daily intake of carbohydrate was determined jointly
by the client and dietitian. This was then broken down into 10 g carbohydrate exchanges.
Clients were asked to keep to an agreed distribution of carbohydrate exchanges in the
form of three main meals and three snacks
Drop-out rate: not known
Providers: dietitian and doctor
Risk of bias
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 79
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
McCulloch 1983 (Continued)
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk Missing outcome data balanced in numbers
across intervention groups, with similar
reasons for missing data across groups
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Unclear risk Baseline balance between groups. Diet adherence
is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported
Meland 1994
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: Norway
Chronic disease: hypertension (management)
Type of participants: clients (n = 34)
Mean age: intervention (53), control (52)
Sex: intervention (F: 37%, M: 63%) and control (F: 47%, M: 53%)
Ethnicity: intervention and control groups: 100% Caucasian
Interventions Group 1: single intervention: training (feedback); 12 weeks; (n = 15)
Clients measured their fasting morning chloride concentration on six different occasions
during the trial. A recommendation of 30 to 50% reduction of urine chloride concentration
compared with the initial value at the inclusion visit was set.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 80
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Meland 1994 (Continued)
Group 2: control (no self-monitoring); 1 month: (n = 19)
Outcomes Measurement of diet adherence: adherence to sodium-restricted diet assessed by urine
sodium excretion (baseline, 1 month, 3 months)
Notes Dietary advice: fresh fish and meat should be preferred for dinner (canned, salted or
smoked food is only rarely allowed), fruit and vegetables should be used plentifully, boil
potatoes without salt, salt should not be used during food processing, spices and herbs
should be used plentifully, lemon juice adds flavour to your food, roasting your food
in the oven or microwave conserves its natural flavours, when frying, use oil instead of
butter, ask for salt-reduced soups or sauces, for baking bread, use 1 teaspoon salt/litre of
liquid
Drop-out rate: 0%
Provider: general practitioner
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generation referring to a random
number table.
Allocation concealment (selection bias) Low risk Allocation concealment using sequentially
numbered, opaque, sealed envelopes
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data.
Selective reporting (reporting bias) High risk No protocol. Some outcomes of interest are
reported incompletely (weight and HDLcholesterol)
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed by
objective measure
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 81
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Micco 2007
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: research center
Country: United States
Chronic disease: overweight and obesity (prevention and management)
Type of participants: clients (n = 123)
Mean age: intervention (47.1 ± 11.1),control (46.5 ± 10.7)
Sex: intervention (F: 89%, M: 12%) and control (F: 77%, M: 23%)
Ethnicity: intervention(100% White, 0% Black), control (98% White, 2% Black)
Interventions Group 1: single intervention: education (individual session with a dietitian); 12 months;
(n = 61)
Monthly, clients attended an in-person meeting in place of an online chat.
Group 2: control (online chat without in-person meeting); 12 months; (n = 62)
Outcomes Measurement of diet adherence: adherence to energy intake assessed by the Block 98.2
food frequency questionnaire (baseline, 6 months, 12 months)
Notes Dietary advice: 1200 to 2100 calorie diet based on baseline body weight, eating a diet
abundant in fruit, vegetables and whole grains and moderate in fat, sugar, salt, and
alcohol
Drop-out rate: 21%
Providers: dietitian and master’s level graduate student
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement.
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Micco 2007 (Continued)
Selective reporting (reporting bias) High risk No protocol.Weekly goals met (calories) is
reported incompletely
Other bias Unclear risk Baseline imbalance between groups (body
weight) but repeated measures analysis of
covariance was performed to control for
baseline weight differences.Diet adherence
is assessed by self-reported measure. Validation
and reliability of self-reported diet
adherence are not reported
Miller 1988
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: United States
Chronic disease: myocardial infarction (management)
Type of participants: clients (n = 115)
Mean age: intervention and control groups: 54
Sex: intervention (F: 27%, M: 73%) and control (F: 11%, M: 89%)
Ethnicity: intervention (98% White, 2% Black), control (87% White, 13% Black)
Interventions Group 1: multiple intervention: individual session with nurse + barrier identification/
problem solving, goal setting; 60 days; (n = 58)
Clients completed a cardiac rehabilitation program during hospitalization and were visited
at home 30 days after discharge. The intervention included a discussion of assessment
data, identification of problems and establishment of goals.
Group 2: control (no nurse intervention); duration: not known; (n = 57)
Outcomes Measurement of diet adherence: adherence to diet assessed by the Health Behavior scale
(Baseline, 30 days, 60 days, 1 year, 2 years)
Notes Dietary advice: not known
Drop-out rate: 55.7% (calculated)
Providers: cardiovascular nurses
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) High risk “During hospitalization, 115 subjects were
alternately assigned to an experimental (n
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 83
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Miller 1988 (Continued)
= 58) or control group (n = 57).”
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) High risk No protocol. Some outcomes of interest
in the review are reported incompletely
(weight, blood pressure)
Other bias Low risk Baseline balance between groups. Diet adherence
is assessed by self-reportedmeasure
(validated Health Behavior scale)
Morey 2008
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: end-stage kidney failure (management)
Type of participants: clients (n = 67)
Mean age: intervention (60.4 ± 15.6), control (54.9 ± 15.9)
Sex: intervention (F: 26.5%, M: 73.5%) and control (F: 48.5%, M: 51.5%)
Ethnicity: intervention (52.9% White, 20.6% Indo-Asian, 14.7% Black, 11.8% Other)
, control (48.5% White, 15.2% Asian, 30.3% Black, 6.1% Other)
Interventions Group 1: multiple intervention: individual session with dietitian + educational toolsbooklet
+ reminder + motivational interviewing; 6 months; (n = 34)
Clients received a monthly dietetic consultation. A variety of strategies were employed
to encourage dietary modification including motivational counseling, negotiation, behaviourmodification
therapy, reminders, reinforcement, supportive care and written and
verbal education.
Group 2: control (no dietetic consultation); once; (n = 33)
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Morey 2008 (Continued)
Outcomes Measurement of diet adherence: adherence to phosphate-restricted diet assessed by serum
phosphate concentrations (baseline, 3 months, 6 months, 12 months)
Notes Dietary advice: phosphate-restricted diet
Drop-out rate: 1.5% (calculated)
Provider: dietitian
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Random number generation”.
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk Missing outcomes are balanced between
groups and the proportion of missing outcomes
compared with observed event risk
not enough to have a clinically-relevant impact
on the intervention effect estimate
Selective reporting (reporting bias) High risk No protocol. Achieving target phosphate
(at 6 months) is reported incompletely
Other bias Low risk Baseline balance between groups . Diet adherence
is assessed by objective measure
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 85
Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Racelis 1998
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: United States
Chronic disease: peripheral artery disease (management)
Type of participants: clients (n = 21)
Mean age: intervention (53), control (49)
Sex: intervention (F: 27.3%, M: 72.7%) and control (F: 20%, M: 80%)
Ethnicity: not known
Interventions Group 1: single intervention: education (telephone follow-up); 12 months; (n = 11)
Clients received quarterly a telephone call to reinforce smoking cessation and diet information
Group 2: control (no telephone follow-up); once; (n = 10)
Outcomes Measurement of diet adherence: adherence assessment not known
Notes Dietary advice: not known
Drop-out rate: 0% (calculated)
Providers: advanced practice nurses and physicians
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk Only one missing data. The reason for this
missing data not likely related to true outcome
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Racelis 1998 (Continued)
Selective reporting (reporting bias) High risk No protocol.Diet adherence is reported incompletely.
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is not clearly
defined
Ryan 2002
Methods Study design: randomized controlled trial with two intervention groups and one control
group
Participants Setting: outpatient
Country: Canada
Chronic disease: type II diabetes (management)
Type of participants: clients (n = 75)
Mean age: intervention group 1 (56.6 ± 8.0), intervention group 2 (57.5 ± 10.7), control
(54.7 ± 14.1)
Sex: intervention group 1 (F: 50%, M: 50%), intervention group 2 (F: 45.8%, M: 54.
2%) and control (F: 63.4%, M: 36.6%)
Ethnicity: not known
Interventions Group 1: single intervention: persuasion (reminder); 6 months; (n = 18)
Knowledge and self-care practice, which serve as a reminder, were assessed at 2 weeks, 3
months and 6 months.
Group 2: single intervention: persuasion (reminder); 6 months; (n = 24)
Knowledge and self-care practice, which serve as a reminder, were assessed at 3 months
and 6 months.
Group 3: control (no reminder); 6 months; (n = 33)
Outcomes Measurement of diet adherence: adherence to frequency of meals and snacks assessed by
a simple question of frequency of meals and snacks (Baseline, 4 days, 2 weeks, 3 months,
6 months)
Notes Dietary advice: eating 3 meals and 3 snacks/day
Drop-out rate: 0%
Providers: nurses, dietitians, physicians, exercise physiologist, podiatrist, ophthalmologist
A second control group was included in this study. Since this control group was not
randomized, this group was not described in the Cochrane review
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generated by shuffling cards or
envelopes.
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Ryan 2002 (Continued)
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk No missing data.
Selective reporting (reporting bias) High risk No protocol. Some outcomes of interest
in the review are reported incompletely
(diet adherence, exercise, glucose monitoring
and weight)
Other bias High risk Baseline imbalance between groups (percentage
of males, body mass index). Diet
adherence is assessed by self-reported measure.
Validation and reliability of self-reported
diet adherence are not reported.
Some patients attending the program gave
kind donation
Scisney-Matlock 2006
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: United States
Chronic disease: hypertension (management)
Type of participants: clients (n = 27)
Mean age: not described
Sex: intervention and control groups (F: 100%)
Ethnicity: intervention (7 Caucasian, 6 Minority), control (7 Caucasian, 7 Minority)
Interventions Group 1: single intervention: modelling (nutritional tools); 30 days; (n = 13)
Clients were exposed to a Cognitive Representations of the Dietary Approaches to Stop
Hypertension (DASH) diet program consisting in three separate paper wheels (knowledge
dimension, attitude dimension and skill dimension) and a bar chart displaying
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 88
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Scisney-Matlock 2006 (Continued)
their baseline Cognitive Representations of the DASH diet. All three wheels contained
the same set of 18 goals. For each goal, each wheel contained one message framed to
support that goal in the information dimension of that wheel. Clients were instructed
to do the following every morning for a 30-day period: review an unhealthy Cognitive
Representations of the DASH diet from her bar chart, use the wheels to view the three
messages for that goal, and record in the notebook the feelings and thoughts she has
about the goal she selected.
Group 2: control (no wheel nor bar chart); 30 days; (n = 14)
Outcomes Measurement of diet adherence: adherence to DASH diet assessed by the Health Promotion
Lifestyle Profile survey (baseline, 30 days, 60 days, 90 days)
Notes Dietary advice: DASH diet
Drop-out rate: not known
Providers: not known
Two control groups were included in this study. Since patients in these control groups
did not follow the DASH diet, these control groups were not described in the Cochrane
review
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “Then, researchers used a computer program
to randomise participants”
Allocation concealment (selection bias) Unclear risk “Group assignment was determined in numerical
sequence from 48 numbered envelopes
matching the stratified sampling
criteria representative of a Salomon Four-
Group Design.”
Blinding (performance bias and detection
bias)
Participants
Low risk “(…) study participants were unaware of
their group assignments”
Blinding (performance bias and detection
bias)
Providers
High risk “Because researchers provided one of the
experimental groups, but not either control
group, (…) the study was not blinded to the
researchers”
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk Insufficient reporting of attrition to permit
judgement
Selective reporting (reporting bias) Unclear risk No protocol.
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Scisney-Matlock 2006 (Continued)
Other bias Low risk Baseline balance between groups. Diet adherence
is assessed by self-reportedmeasure
(Health Promotion Lifestyle Profile survey)
. Internal consistency of Health Promotion
Lifestyle Profile survey described
Stewart 2005
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: South Africa
Chronic disease: hypertension (management)
Type of participants: clients (n = 83)
Mean age: intervention (56.3 ± 11.5), control (58.6 ± 11.2)
Sex: intervention (F: 70.7%, M: 29.3%) and control (F: 66.7%, M: 33.3%)
Ethnicity: intervention (26.8% Black, 41.5% Coloured-mixed, 14.6% Indians, 17.1%
White), control (14.3% Black, 54.8% Coloured-mixed, 23.8% Indians, 7.1% White
Interventions Group 1: single intervention: education (telephone follow-up); 24 weeks; (n = 41)
Clients received monthly a telephone call to provide support.
Group 2: control (no telephone follow-up); 24 weeks; (n = 42)
Outcomes Measurement of diet adherence: non-adherence to alcohol intake and adherence to
sodium-restricted diet assessed by a yes/no question (baseline, 24 weeks, 36 weeks)
Notes Dietary advice: prudent diet
Drop-out rate: 63.9% (calculated)
Provider: physiotherapist
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Sequence generated by drawing of lots
(clear or colored balls from a closed bag)
Allocation concealment (selection bias) Low risk Allocation concealment using central allocation.
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
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Stewart 2005 (Continued)
Blinding (performance bias and detection
bias)
Outcome assessors
Low risk “The first author and a research assistant
undertook all reassessments. Neither the
first author nor the research assistant had
been involved in the intervention and they
were blinded to the data obtained at baseline
and to which groups the patients belonged.”
Incomplete outcome data (attrition bias)
All outcomes
High risk The proportion of missing outcomes compared
with observed risk enough to induce
clinically-relevant bias in intervention effect
estimate
Selective reporting (reporting bias) High risk No protocol. Blood pressure is reported incompletely.
Other bias High risk Baseline imbalance between groups (alcohol
adherence). Diet adherence is assessed
by self-reported measures. Validation and
reliability of self-reported diet adherence
are not reported
Tsay 2003
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting: outpatient
Country: Taiwan
Chronic disease: end-stage renal disease (management)
Type of participants: clients (n = 64)
Mean age: intervention (57.51 ± 11.41), usual care (57.94 ± 11.62)
Sex: intervention and usual care groups (F: 58.1%, M: 41.9%)
Ethnicity: not known
Interventions Group 1: multiple intervention: stress management, goal setting + feedback; 4 weeks; (n
= 32)
The program consisted of 12 sessions conducted three times per week while clients
were receiving dialysis. Clients learned to relax muscles through listening to audiotaped
instructions. Clients were encouraged to set attainable objectives such as ‘decreasing a
cup of tea or water a day’. If the goals were achieved, praise and recognition rewards
were given. Individual counselling sessions were offered stressing physical and emotional
adjustment to the chronic illness. Clients recorded their food and liquid intake daily,
and these records were reviewed during each treatment.
Group 2: usual care; duration: not known; (n = 32)
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Tsay 2003 (Continued)
Outcomes Measurement of diet adherence: adherence to fluid-restricted diet assessed by mean
weight gains between dialysis sessions (baseline, 1 month, 3 months, 6 months)
Notes Dietary advice: fluid-restricted diet
Drop-out rate: 3.1% (calculated)
Providers: nephrology nurse specialists, physicians, dietitians, social workers
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Low risk “Only the researcher knewwhich treatment
patients were receiving, and care providers
were not informed of participant’s treatment
group.”
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
Low risk Plausible effect size among missing outcomes
not enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias Low risk Baseline imbalance for body weight change
but baseline differences in weight gain between
groups were taken into account in
the repeated-measured analysis by using the
baseline values as a covariate. Diet adherence
is assessed by objective measure
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Wong 2010
Methods Study design: randomized controlled trial with one intervention group and one control
group
Participants Setting: outpatient
Country: China
Chronic disease: renal failure (management)
Type of participants: clients (n = 120)
Mean age: intervention and control groups (62.4)
Sex: intervention and control groups (F: 46.9%, M: 53.1%)
Ethnicity: not known
Interventions Group 1: multiple intervention: telephone follow-up + goal setting; 6 weeks; (n = 60)
Clients received a weekly telephone call consisting to monitoring changes from the specific
health concerns identified in the previous interaction, monitoring progress, providing
health advice, reinforcing health self-management behaviours, and assessing need for
referral and reviewing the health goals with the patient and setting mutual goals
Group 2: control (no telephone follow-up); duration: not known; (n = 60)
Outcomes Measurement of diet adherence: non-adherence to diet and fluid-restricted diet assessed
by dialysis diet and fluid non-adherence questionnaire (baseline, 7 weeks, 13 weeks)
Notes Dietary advice: dialysis diet and fluid-restricted diet
Drop-out rate: 18.3% (calculated)
Providers: renal nurses and general nurses
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “120 sets of computer-generated random
numbers were used, and patients who fitted
the criteria were randomised to the study
or control group.”
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
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Wong 2010 (Continued)
Incomplete outcome data (attrition bias)
All outcomes
High risk Plausible effect size among missing outcomes
enough to have a clinically-relevant
impact on observed effect size
Selective reporting (reporting bias) High risk No protocol. Some outcomes of interest
in the review are reported incompletely
(blood glucose, HDL-cholesterol, triglyceride)
Other bias Low risk Baseline balance between groups. Diet adherence
is assessed by self-reportedmeasure
(validated questionnaire)
Wood 2008
Methods Study design: cluster-randomized controlled trial with two populations including one
intervention group and one usual care group each
Two populations were studied in this study: clients with coronary heart disease (population
1) and clients at high risk of cardiovascular disease (population 2)
Participants Setting:
• Population 1: outpatient
• Population 2: outpatient
Country:
• Population1: France, Italy, Poland, Spain, Sweden, United Kingdom
• Population2: Denmark, Italy, Poland, Spain, Netherlands, United Kingdom
Chronic disease:
• Population 1: coronary heart disease (management)
• Population 2: high risk of coronary heart disease (prevention)
Type of participants:
• Population 1: clients (n = 3088)
• Population 2: clients (n = 2317)
Mean age:
• Population 1: intervention (62.5 ± 9.9), usual care (63.0 ± 9.6)
• Population 2: intervention (62.0 ± 7.6), usual care (62.8 ± 7.3)
Sex:
• Population 1: intervention (F: 30%, M: 70%) and usual care (F: 30%, M: 70%)
• Population 2: intervention (F: 50%, M: 50%) and usual care (F: 43%, M: 57%)
Ethnicity: not known
Interventions Population 1 :
Group 1: multiple intervention: individual session with nurse + motivational interviewing;
(n = 1589)
Clients and their partners attended at least eight weekly sessions with multidisciplinary
team using stages of change and motivational interviews. Clients were provided with
a personal record card for lifestyle and risk factor targets. Nurses also coordinated a
rolling program of eight weekly workshops for coronary heart disease, cardiovascular risk
(lifestyle and risk factors control), cardioprotective medication and return to work and
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 94
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Wood 2008 (Continued)
leisure.
Group 2: usual care; duration: not known; (n = 1499)
Population 2:
Group 1: multiple intervention: individual session with nurse + motivational interviewing;
(n = 1189)
Clients and their partners attended at least eight weekly sessions with nurse and the
family doctor using stages of changes and motivational interviews. Clients were provided
with a personal record card for lifestyle and risk factor targets. Nurses also coordinated
a rolling program of eight weekly workshops for lifestyle and risk factors.
Group 2: usual care; duration: not known; (n = 1128)
Outcomes Measurement of diet adherence: adherence to saturated fat, oily fish, fish, and fruit and
vegetables intake assessed by a food-habit questionnaire (baseline, 1 year)
Notes Dietary advice: < 10% of energy from saturated fat, > 400 g/day of fruit and vegetables,
> 20 g/day of fish, > 3 times/week of oily fish, < 30 g/day of alcohol
Drop-out rate: not known
Providers:
• Population 1: nurses, dietitians, physiotherapists, cardiologists
• Population 2: nurses, family doctors
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk Sequence generation is not described explicitly
in the paper
Allocation concealment (selection bias) Unclear risk Allocation concealment is not described explicitly
in the paper
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Unclear risk This study did not assess this item.
Incomplete outcome data (attrition bias)
All outcomes
High risk The proportion of missing outcomes compared
with observed risk enough to induce
clinically-relevant bias in intervention effect
estimate
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Wood 2008 (Continued)
Selective reporting (reporting bias) High risk No protocol. Some outcomes of interest
in the review are reported incompletely
(HDL-cholesterol, triglyceride)
Other bias Unclear risk Baseline comparisons between groups are
not reported. Diet adherence is assessed by
self-reportedmeasure (validated food habit
questionnaire)
Zhao 2004
Methods Study design: randomized controlled trial with one intervention group and one usual
care group
Participants Setting: outpatient
Country: China
Chronic disease: coronary heart disease (management)
Type of participants: clients (n = 220)
Mean age: intervention (72.9 ± 6.4), usual care (71.6 ± 4.1)
Sex: intervention (F: 49%, M: 51%) and usual care (F: 53%, M: 47%)
Ethnicity: not known
Interventions Group 1: multiple intervention: telephone follow-up + individual session with a nurse
+ goal setting; 4 weeks; (n = 107)
Nurse provided one home visit on the second day after discharge and another in the
third week and made two telephone calls in the second and fourth weeks. Nurse set goals
with the clients and assessed whether the clients achieved them.
Group 2: usual care (no visit nor telephone follow-up) ; duration: not known; (n = 113)
Outcomes Measurement of diet adherence: adherence to diet assessed by a seven-day recall questionnaire
(baseline, 4 weeks, 12 weeks)
Notes Dietary advice: not known
Drop-out rate: 9.1% (calculated)
Providers: nurses
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk “The patients who agreed to participate
would be assigned to the study or control
group using a computer-generated randomised
table, with a computer number
”0“ belonged to the control group and ”1“
the study group.”
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Zhao 2004 (Continued)
Allocation concealment (selection bias) Low risk “…the head nurse asked the eligible patients
to draw sealed envelop that contained a slip
indicating the group the patient be entered.
..”
Blinding (performance bias and detection
bias)
Participants
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Providers
Unclear risk This study did not assess this item.
Blinding (performance bias and detection
bias)
Outcome assessors
Low risk “The measurement team was blinded of
which group the subjects were in.”
Incomplete outcome data (attrition bias)
All outcomes
Low risk Missing outcome data balanced in numbers
across intervention groups, with similar
reasons for missing data across groups
Selective reporting (reporting bias) Unclear risk No protocol.
Other bias High risk Baseline imbalance between groups (number
of chronic diseases). Diet adherence is
assessed by self-reportedmeasure (validated
7-day recall questionnaire)
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Abramson 1980 No measure of adherence outcome.
Agras 1996 Provision of meals, food items or dietary supplements.
Ammerman 2003 No measure of adherence outcome.
Arnaud-Battandier 1999 Provision of meals, food items or dietary supplements.
Ashurst 2003 Interventions had not the same dietary advice component.
Atwood 1992 Interventions had not the same dietary advice component.
Babamoto 2009 No measure of adherence outcome.
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(Continued)
Basler 1982 No measure of adherence outcome.
Baum 1991 No measure of adherence outcome.
Befort 2008 No measure of adherence outcome.
Berra 2007 No measure of adherence outcome.
Berteus 2008 Interventions had not the same dietary advice component.
Bertram 1990 Intervention not intended to improve diet adherence.
Boeka 2010 No measure of adherence outcome.
Borg 2002 No measure of adherence outcome.
Bosworth 2008 No measure of adherence outcome.
Brekke 2003 No measure of adherence outcome.
Brekke 2005a No measure of adherence outcome.
Brekke 2005b No measure of adherence outcome.
Brekke 2009 No measure of adherence outcome.
Broekhuizen 2010 No measure of adherence outcome.
Bruckert 2008 Interventions had not the same dietary advice component.
Burke 2005 Interventions had not the same dietary advice component.
Burke 2006a No measure of adherence outcome.
Burke 2006b No measure of adherence outcome.
Burke 2007 No measure of adherence outcome.
Burke 2008 No measure of adherence outcome.
Burke 2010 No measure of adherence outcome.
Burkett 1990 No measure of adherence outcome.
Campbell 1984 No measure of adherence outcome.
Campbell 1990 Interventions had not the same dietary advice component.
Campbell 1998 Interventions had not the same dietary advice component.
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(Continued)
Cangiano 1991 Provision of meals, food items or dietary supplements.
Cangiano 1992 Provision of meals, food items or dietary supplements.
Cangiano 1998 Provision of meals, food items or dietary supplements.
Carels 2005 Interventions had not the same dietary advice component.
Carels 2005a Interventions had not the same dietary advice component.
Carson 1988 No measure of adherence outcome.
Casebeer 1999 No measure of adherence outcome.
Cegala 2000 No measure of adherence outcome.
Chang 2009 No measure of adherence outcome.
Cheyette 2007 No measure of adherence outcome.
Chlebowski 1993 Interventions had not the same dietary advice component.
Costa 2008 No measure of adherence outcome.
Darlington 1986 No measure of adherence outcome.
Davidson 1996 Provision of meals, food items or dietary supplements.
De Zwaan 2005 Provision of meals, food items or dietary supplements.
Dechamps 2009 No measure of adherence outcome.
Del 2009 Provision of meals, food items or dietary supplements.
Demark-Wahnefried 2006 Interventions had not the same dietary advice component.
Dennis 2001 No measure of adherence outcome.
Digenio 2009 Interventions had not the same dietary advice component.
Domenech 1995 Interventions had not the same dietary advice component.
Donnelly 2003 Provision of meals, food items or dietary supplements.
Dyson 1997 No measure of adherence outcome.
Eriksson 2009 No measure of adherence outcome.
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(Continued)
Evers 1987 Interventions had not the same dietary advice component.
Farmer 2009 No measure of adherence outcome.
Fehily 1991 Interventions had not the same dietary advice component.
Ferrante 2010 Interventions had not the same dietary advice component.
Fitzgibbon 2005 No measure of adherence outcome.
Forget 1990 Provision of meals, food items or dietary supplements.
Forli 2001 Provision of meals, food items or dietary supplements.
Forrester 2010 Interventions had not the same dietary advice component.
Fox 1996 No measure of adherence outcome.
Frohling 1990 Provision of meals, food items or dietary supplements.
Frost 2007 Interventions had not the same dietary advice component.
Fuchs 1993 No measure of adherence outcome.
Glasgow 2003 No measure of adherence outcome.
Gorin 2010 No measure of adherence outcome.
Grancelli 2003 Interventions had not the same dietary advice component.
Greene 1977 No measure of adherence outcome.
Hakala 1993 Provision of meals, food items or dietary supplements.
Hartwell 1986 No measure of adherence outcome.
Harvey-Berino 2004 No measure of adherence outcome.
Harvey-Berino 2009 No measure of adherence outcome.
Hebert 2001 Interventions had not the same dietary advice component.
Henkin 2000 Interventions had not the same dietary advice component.
Heraief 1985 Provision of meals, food items or dietary supplements.
Hyman 1998 No measure of adherence outcome.
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(Continued)
Jolly 1998 No measure of adherence outcome.
Jolly 2007 No measure of adherence outcome.
Jones 2003 No measure of adherence outcome.
Jula 1990 Interventions had not the same dietary advice component.
Kaiman 2000 Provision of meals, food items or dietary supplements.
Kalodner 1991 Interventions had not the same dietary advice component.
Kalter-Leibovici 2010 No measure of adherence outcome.
Kattelmann 2009 Interventions had not the same dietary advice component.
Khoo 2007 Provision of meals, food items or dietary supplements.
Kim 2006 No measure of adherence outcome.
Kirkman 1994 Interventions had not the same dietary advice component.
Koelewijn-van Loon 2009 Interventions had not the same dietary advice component.
Korhonen 1983 No measure of adherence outcome.
Korhonen 2003 No measure of adherence outcome.
Krier 1999 Interventions had not the same dietary advice component.
Kumanyika 1993 Interventions had not the same dietary advice component.
Lampman 1977 Interventions had not the same dietary advice component.
Laws 2004 No measure of adherence outcome.
Leermakers 1999 Intervention not intended to improve diet adherence
Lesley 2007 No measure of adherence outcome.
Lindahl 2009 Not a real-life setting.
Locatelli 1990 Interventions had not the same dietary advice component.
Lopez 2006 No measure of adherence outcome.
Manchanda 2000 Interventions had not the same dietary advice component.
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(Continued)
Mathus-Vliegen 1993 Intervention not intended to improve diet adherence
McCarron 1998 Provision of meals, food items or dietary supplements.
McConnon 2007 No measure of adherence outcome.
McConnon 2009 No measure of adherence outcome.
Melchionda 2006 No measure of adherence outcome.
Melin 2003 Not a real-life setting.
Metz 1997 Provision of meals, food items or dietary supplements.
Metz 2000 Provision of meals, food items or dietary supplements.
Mhurchu 1998 No measure of adherence outcome.
Milas 1995 Interventions had not the same dietary advice component.
Miller 2009 Interventions had not the same dietary advice component.
Morgan 2009 No measure of adherence outcome.
Nir 2004 Interventions had not the same dietary advice component.
Nugent 1984 No measure of adherence outcome.
Oldroyd 2006 Interventions had not the same dietary advice component.
Ornish 1998 Interventions had not the same dietary advice component.
Pater 2000 No measure of adherence outcome.
Pettman 2008 No measure of adherence outcome.
Pierce 1997 Interventions had not the same dietary advice component.
Pierce 2002 Interventions had not the same dietary advice component.
Pierce 2007 Interventions had not the same dietary advice component.
Pijls 2000 Interventions had not the same dietary advice component.
Pringle 1993 No measure of adherence outcome.
Rabkin 1983 No measure of adherence outcome.
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(Continued)
Racette 1995 Interventions had not the same dietary advice component.
Rallidis 2009 Provision of meals, food items or dietary supplements.
Rhew 2007 Study did not involve a nutritional intervention
Rimmer 2000 No measure of adherence outcome.
Robertson 1992 No measure of adherence outcome.
Rosman 1989 Interventions had not the same dietary advice component.
Rosman 1990 Interventions had not the same dietary advice component.
Roumen 2008 No measure of adherence outcome.
Sadur 1999 No measure of adherence outcome.
Sartorio 2003 No measure of adherence outcome.
Schapira 1991 No measure of adherence outcome.
Sevick 2008 Interventions had not the same dietary advice component.
Shaw-Stuart 2000 No measure of adherence outcome.
Singh 1991 Interventions had not the same dietary advice component.
Singh 1992 Interventions had not the same dietary advice component.
Sisk 2006 No measure of adherence outcome.
Smith 1997 No measure of adherence outcome.
Sone 2010 No measure of adherence outcome.
Southard 2003 No measure of adherence outcome.
Sperduto 1986 No measure of adherence outcome.
Thoolen 2009 No measure of adherence outcome.
Tilley 1997 No measure of adherence outcome.
Toobert 1998 Interventions had not the same dietary advice component.
Toobert 2000 Interventions had not the same dietary advice component.
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(Continued)
Torgerson 1999 Provision of meals, food items or dietary supplements.
Tsang 2001 No measure of adherence outcome.
Vale 2003 Interventions had not the same dietary advice component.
van der Weijden 1998 Interventions had not the same dietary advice component.
van Gool 2006 Interventions had not the same dietary advice component.
Verges 1998 No measure of adherence outcome.
Voils 2009 No measure of adherence outcome.
von Gruenigen 2008 No measure of adherence outcome.
Wadden 1997 No measure of adherence outcome.
Wadden 2009 Provision of meals, food items or dietary supplements.
Webber 2010 No measure of adherence outcome.
Wing 1986 No measure of adherence outcome.
Wing 1996 No measure of adherence outcome.
Wing 1999 No measure of adherence outcome.
Wing 2003 Intervention not intended to improve diet adherence.
Witmer 2004 No measure of adherence outcome.
Wright 1981 No measure of adherence outcome.
Zismer 1982 No measure of adherence outcome.
Characteristics of studies awaiting assessment [ordered by study ID]
Aldous 2009
Methods Study design: not known
Participants Setting: not known
Country: Canada
Chronic disease: not known
Type of participants: clients
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Aldous 2009 (Continued)
Interventions The intervention Community Cardiovascular Hearts in Motion is a multidisciplinary, multi-vascular program combining
nutrition intervention, weekly exercise, and risk factor management including motivational interviewing and
behaviour change techniques
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: dietitian
No response to attempted contact with author.
Amato 1990
Methods Study design: randomized controlled trial with one intervention group and one usual care group
Participants Setting: not known
Country: Italy
Chronic disease: obesity (management)
Type of participants: clients
Interventions The study compared an intervention using a psychological therapy combined with the usual diet treatment with an
usual care group receiving only the usual diet
Outcomes Measurement of diet adherence: adherence to diet
Notes Dietary advice: not known
Provider: not known
The study was published in Italian and only the abstract was available in English
Clark 2004
Methods Study design: randomized controlled trial with one intervention group and one usual care group
Participants Setting: outpatient
Country: United Kingdom
Chronic disease: type II diabetes (management)
Type of participants: clients
Interventions A brief, tailored lifestyle self-management intervention including assessment, clients’ participation in goal setting,
selection of personalized strategies to overcome barriers
Outcomes Measurement of diet adherence: adherence to fat restriction assessed by the Kristal Food Habits Questionnaire and the
Block Fat Screener
Notes Dietary advice: not known
Provider: not known
The corresponding author was contacted in order to have more information about the dietary advice provided in
both groups. However, no response to attempted contact with author
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Contel 1993
Methods Study design: not known
Participants Setting: not known
Country: not known
Chronic disease: not known
Type of participants: not known
Interventions Not known
Outcomes Measurement of diet adherence: not known
Notes Diet: not known
Provider: not known
Abstract unobtainable.
Duncan 2001
Methods Study design: randomized controlled trial with one intervention group and one control group
Participants Setting: not known
Country: United States
Chronic disease: congestive heart failure (management)
Type of participants: clients
Interventions A behavioural intervention consisting of feedback on the three-day sodium intake of the clients and a discussion of
problem-solving strategies to reduce future sodium intake was compared to a control group. Both groups received
the usual dietary education class
Outcomes Measurement of diet adherence: adherence to dietary sodium advice assessed by a three-day dietary intake log
Notes Dietary advice: sodium-restricted diet
Provider: not known
Contact with author: data no longer available. Therefore, the inclusion criteria of use of provision of meals, food
items or dietary supplements could not be assessed
Fernández López 2007
Methods Study design: randomized controlled trial with two intervention groups and one control group
Participants Setting: outpatient
Country: Spain
Chronic disease: hypertension (management)
Type of participants: clients
Interventions The study compared an educative sessions intervention and an intervention consisting to provide written information
to clients with a control group
Outcomes Measurement of diet adherence: not known
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Fernández López 2007 (Continued)
Notes Dietary advice: not known
Providers: nurses
No response to attempted contact with author(s).
Firth 2009
Methods Study design: not known
Participants Setting: not known
Country: Canada
Chronic disease: not known
Type of participants: clients
Interventions The intervention was a web-based, self-monitoring wellness program
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: not known
No response to attempted contact with author.
González 1987
Methods Study design: not known
Participants Setting: not known
Country: not known
Chronic disease: not known
Type of participants: not known
Interventions Not known
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: not known
Abstract unobtainable.
Hauner 2006
Methods Study design: randomized controlled trial with one intervention group and one usual care group
Participants Setting: not known
Country: Germany
Chronic disease: type II diabetes (management)
Type of participants: clients
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Hauner 2006 (Continued)
Interventions The study compared an intense nutritional training program (diet, knowledge about diabetes, physical activities and
other lifestyle factors) with an usual care group
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: not known
No response to attempted contact with author.
Kim 2003
Methods Study design: randomized controlled trial with one intervention group and one control group
Participants Setting: outpatient
Country: Korea
Chronic disease: type II diabetes (management)
Type of participants: clients
Interventions The study compared a telephone follow-up intervention including self-monitoring blood glucose levels, diet and
exercise, feedback from a dietitian and an informative booklet with a control group
Outcomes Measurement of diet adherence: adherence to diet assessed by a self-reported adherence questionnaire
Notes Dietary advice: not known
Providers: nurse, dietitian
The corresponding authors were contacted in order to have more information about the dietary advice provided in
both groups. However, no response to attempted contact with authors
Koprucki 2010
Methods Study design: randomized controlled trial with one intervention group and one control group
Participants Setting: not known
Country: United States
Chronic disease: chronic kidney disease (management)
Type of participants: clients
Interventions The study compared an intervention group in which clients monitored dietary intake with a personal digital assistant
(PDA) programmed with their dietary prescription and received PDA feedback regarding%of daily targets consumed
and counselling based on Social Cognitive Theory with a control group
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: sodium-restricted diet
Provider: not known
Contact with author(s): information provided does not allow including or excluding the study
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 108
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Lin 2007
Methods Study design: randomized controlled trial with three intervention groups
Participants Setting: community
Country: Taiwan
Chronic disease: overweight and obesity (prevention/management)
Type of participants: clients
Interventions The study compared: 1) an individualized weight control education, 2) a group weight control education and 3) a
mail-delivered weight control education
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: not known
No response to attempted contact with authors.
Martínez-Marcos 1999
Methods Study design: not known
Participants Setting: not known
Country: not known
Chronic disease: not known
Type of participants: not known
Interventions Not known
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: not known
Abstract unobtainable.
Mayeux 2004
Methods Study design: not known
Participants Setting: not known
Country: United States
Chronic disease: not known
Type of participants: clients
Interventions The study compared an Aramark Nutrition Concepts© Survival Skills diet education using a condensed one-page
handout with a traditional diet education using in-depth material
Outcomes Measurement of diet adherence: adherence to diet assessed by a telephone survey
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 109
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Mayeux 2004 (Continued)
Notes Dietary advice: not known
Provider: dietitian
Address for authors correspondence not found.
Mensink 2003
Methods Study design: randomized controlled trial with one intervention group and one control group
Participants Setting: not known
Country: Netherlands
Chronic disease: glucose intolerance (prevention)
Type of participants: clients
Interventions The study compared an intensive intervention aiming to stimulate the dietary change and the physical activity with
a control group
Outcomes Measurement of diet adherence: adherence to diet assessed by a three-day food record
Notes Dietary advice: Dutch guidelines for a healthy diet (Dutch Nutrition Council)
Providers: dietitians and trainers
The author was contacted in order to obtain more information about the dietary advice provided in both groups.
However, there was no response to our attempted contact with author
Paisey 2005
Methods Study design: randomized controlled trial with one intervention group and one control group
Participants Setting: not known
Country: United Kingdom
Health problem: type II diabetes (management)
Type of participants: clients
Interventions The study compared an intensive group using self-monitoring of food intake and feedback with a control group
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: diabetes United Kingdom guidelines on low fat and complex carbohydrate/ no sugar.
Providers: dietitians and nurses
Contact with author: information do not allow including or excluding the study
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 110
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Simpson 2010
Methods Study design: randomized controlled trial with two intervention groups
Participants Setting: not known
Country: United Kingdom
Chronic disease: obesity (management)
Type of participants: clients
Interventions The study compared an intense intervention using motivational interviewing with a less intense intervention
Outcomes Measurement of diet adherence: not known
Notes Dietary advice: not known
Provider: not known
Contact with author: information do not allow including or excluding the study
Song 2009
Methods Study design: randomized controlled trial with one intervention group and one control group
Participants Setting: outpatient
Country: Korea
Chronic disease: type II diabetes (management)
Type of participants: clients
Interventions The study compared a diabetes outpatient intensive management program including multidisciplinary diabetes
education, complication monitoring and telephone counseling with a control group
Outcomes Measurement of diet adherence: adherence to diet assessed by a self-report questionnaire on adherence
Notes Dietary advice: not known
Providers: endocrinologist, diabetes education nurse, family physician, rehabilitation therapist, dermatologist, psychologist,
dietitian, pharmacist, ophthalmologist and physiotherapist
The corresponding author was contacted in order to obtain more information about the dietary advice provided in
both groups. However, there was no response to attempted contact with author
Stollar 1993
Methods Study design: not known
Participants Setting: not known
Country: not known
Chronic disease: not known
Type of participants: not known
Interventions Not known
Outcomes Measurement of diet adherence: not known
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 111
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Stollar 1993 (Continued)
Notes Dietary advice: not known
Provider: not known
Abstract unobtainable.
Wedman 1987
Methods Study design: not known
Participants Setting: outpatient
Country: United States
Chronic disease: diabetes (management)
Type of participants: clients
Interventions The study compared an intervention using graphic teaching aids with a control group
Outcomes Measurement of diet adherence: adherence to diet assessed by dietitian’s appointment log and by information obtained
during each visit of every client
Notes Dietary advice: decreasing fat consumption, eating meals at regular intervals and controlling portion size
Provider: dietitian
Address for authors correspondence not found.
Characteristics of ongoing studies [ordered by study ID]
Feldman 2009
Trial name or title Home Based Blood Pressure Intervention for Blacks
Methods Study design: cluster-randomized controlled trial with two intervention groups and one usual care group
Participants Setting: outpatient
Country: United States
Chronic disease: hypertension (management)
Type of participants: clients
Interventions Two interventions will be tested and compared to a usual care group: 1) a “basic” intervention delivering key
evidence-based reminders to home care nurses and patients while the patient is receiving traditional postacute
home health care, 2) an “augmented” intervention that includes that same as the basic intervention plus
transition to an ongoing hypertension home support program that extends support for 12 months
Outcomes Measurement of diet adherence: adherence to healthy diet
Starting date Not described
Contact information Dr Penny H. Feldman: pfeldman@vnsny.org
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 112
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Feldman 2009 (Continued)
Notes Dietary advice: Dietary Approaches to Stop Hypertension (DASH) recommendations
Providers: nurses
Griva 2010
Trial name or title The effectiveness of a self-management intervention to improve outcomes in prevalent haemodialysis patients:
a randomised controlled trial
Methods Study design: randomized controlled trial with one intervention group and one usual care group
Participants Setting: outpatient
Country: Singapore
Chronic disease: end-stage renal disease (management)
Type of participants: clients
Interventions One intervention will be tested and compared to an usual care group: a group-based self-management intervention
including address of misconceptions, group discussion of possible coping strategies, identification of
barriers to change, training in specificmanagement strategies, identification of individual goals to be achieved,
formulation of actions plans to achieve these goals and review previously set goals
Outcomes Measurement of diet adherence: adherence to dietary restrictions assessed by values of blood phosphate,
calcium phosphate and potassium levels and gain between dialysis sessions
Starting date August 2010
Contact information Dr Konstadina Griva: Department of Psychology, Faculty of Arts and Social Sciences, National University of
Singapore, Block AS4 #02-28, 9 arts link
Notes Dietary advice: not described
Providers: psychologist, dietitian and nurse
Jansink 2006
Trial name or title Title: Nurse-led motivational interviewing to change the lifestyle of patients with type II diabetes (MILDproject):
protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations
Methods Study design: cluster-randomized controlled trial with one intervention group and one control group
Participants Setting: outpatient
Country: Netherlands
Chronic disease: type II diabetes (management)
Type of participants: clients
Interventions One intervention will be tested and compared to a control group: the clients will receive an intervention using
motivational interviewing. The primary care nurse who will provide the intervention will receive training in
an implementation strategy with motivational interviewing as the core component. Other components of
this strategy will be adaptation of the diabetes protocol to local circumstances, introduction of a social map
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 113
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Jansink 2006 (Continued)
for lifestyle support, and educational and supportive tools for sustaining motivational interviewing
Outcomes Measurement of diet adherence: adherence to diet assessed by a self-reported questionnaire
Starting date March 2007
Contact information Dr Renate Jansink: r.jansink@iq.umcn.nl
Notes Dietary advice: Dutch guidelines norms
Providers: nurses
Ma 2009
Trial name or title Evaluation of lifestyle interventions to treat elevated cardiometabolic risk in primary care (E-LITE): a randomised
controlled trial
Methods Study design: randomized controlled trial with two intervention groups and an usual care group
Participants Setting: outpatient
Country: United States
Chronic disease: overweight and obesity with pre-diabetes and/or metabolic syndrome (prevention and management)
Type of participants: clients
Interventions Two interventions will be tested and compared to an usual care group: 1) information technology-assisted
self-management, 2) information technology-assisted self-management combined with care management
Outcomes Measurement of diet adherence: adherence to diet assessed by a three-day food record
Starting date Not described
Contact information Dr Jun Ma: maj@pamfri.org
Notes Dietary advice: total fat reduction (to 25% of energy), energy balance and restriction (with a goal of a 500-
to 1000-calorie reduction diet), saturated fat intake (to < 10% of energy), cholesterol intake (to < 300 mg/
day), consumption of a high plant-based diet that includes a variety of fruit and vegetables, whole grains, and
low-fat dairy products and reduction of high glycemic index carbohydrates
Providers: dietitian and exercise physiologist
Sher 2002
Trial name or title Partners for life: a theoretical approach to developing an intervention for cardiac risk reduction
Methods Study design: randomized controlled trial with one intervention group and one control group
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 114
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Sher 2002 (Continued)
Participants Setting: outpatient
Country: United States
Chronic disease: coronary artery disease(management)
Type of participants: clients
Interventions A standard behavioral treatment group including a couples intervention will be compared to a standard
behavioral treatment (control)
Outcomes Measurement of diet adherence: adherence to dietary recommendations
Starting date Not described
Contact information Dr Tamara Goldman Sher: t-sher@northwestern.edu
Notes Dietary advice: weight loss or dietary modification based on current American Heart Association recommendations
Providers: therapist
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 115
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D A T A A N D A N A L Y S E S
Comparison 1. Nutritional tools versus control in diet adherence
Outcome or subgroup title
No. of
studies
No. of
participants Statistical method Effect size
1 Continuous data 2 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
1.1 Adherence to energy
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.2 Adherence to protein
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.3 Adherence to fat intake at
6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.4 Adherence to carbohydrate
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.5 Adherence to cholesterol
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.6 Adherence to fiber intake
at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.7 Adherence to sodium
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.8 Adherence to fruit intake
at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.9 Adherence to vegetable
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.10 Adherence to sweet food
intake at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.11 Adherence to energy
intake at 12 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.12 Adherence to fat intake
at 12 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Comparison 2. Multiple interventions versus control in diet adherence
Outcome or subgroup title
No. of
studies
No. of
participants Statistical method Effect size
1 Continuous data 4 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
1.1 Adherence to
sodium-restricted diet at 3
months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.2 Adherence to diet at 3
months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.3 Adherence to
fluid-restricted diet at 1 month
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
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1.4 Adherence to
fluid-restricted diet at 3 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.5 Adherence to
fluid-restricted diet at 6 months
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.6 Non-adherence to diet
(days) at 7 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.7 Non-adherence to diet
(days) at 13 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.8 Non-adherence to diet
(degree) at 7 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.9 Non-adherence to diet
(degree) at 13 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.10 Non-adherence to
fluid-restricted diet (days) at 7
weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.11 Non-adherence to
fluid-restricted diet (days) at 13
weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.12 Non-adherence to
fluid-restricted diet (degree) at
7 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
1.13 Non-adherence to
fluid-restricted diet (degree) at
13 weeks
1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
2 Dichotomous data 5 Risk Ratio (M-H, Random, 95% CI) Totals not selected
2.1 Adherence to
sodium-restricted diet at 18
months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.2 Adherence to fat intake at
3 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.3 Adherence to saturated fat
intake at 3 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.4 Adherence to unsaturated
fat intake at 3 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.5 Adherence to carbohydrate
intake at 3 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.6 Adherence cholesterol
intake at 3 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.7 Adherence to saturated fat
intake at 15 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.8 Adherence to fat intake at
15 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.9 Adherence to unsaturated
fat intake at 15 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.10 Adherence to
carbohydrate intake at 15
months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.11 Adherence to fiber intake
at 15 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.12 Adherence to cholesterol
intake at 15 months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
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2.13 Adherence to
phosphate-restricted diet at 3
months
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.14 Adherence to saturated
fat intake at 1 year – CHD
patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.15 Adherence to oily fish
intake at 1 year – CHD patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.16 Adherence to fish intake
at 1 year – CHD patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.17 Adherence to fruit and
vegetable intake at 1 year –
CHD patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.18 Adherence to oily fish
intake at 1 year – high risk
CHD patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.19 Adherence to fish intake
at 1 year – high-risk CHD
patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.20 Adherence to fruit and
vegetable intake at 1 year –
high-risk CHD patients
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.21 Adherence to diet at 4
weeks
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
2.22 Adherence to diet at 12
weeks
1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 118
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Analysis 1.1. Comparison 1 Nutritional tools versus control in diet adherence, Outcome 1 Continuous data.
Review: Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults
Comparison: 1 Nutritional tools versus control in diet adherence
Outcome: 1 Continuous data
Study or subgroup Control Experimental
Std.
Mean
Difference
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Adherence to energy intake at 6 months
Assuncao 2010 95 -421.7 (3196.95) 97 -1299.1 (2966.48) 0.28 [ 0.00, 0.57 ]
2 Adherence to protein intake at 6 months
Assuncao 2010 95 0.9 (5.85) 97 2 (4.92) -0.20 [ -0.49, 0.08 ]
3 Adherence to fat intake at 6 months
Assuncao 2010 95 -2.6 (7.8) 97 -2.5 (7.88) -0.01 [ -0.30, 0.27 ]
4 Adherence to carbohydrate intake at 6 months
Assuncao 2010 (1) 95 -1.7 (9.75) 97 -0.2 (8.9) -0.16 [ -0.44, 0.12 ]
5 Adherence to cholesterol intake at 6 months
Assuncao 2010 95 -29.2 (101.37) 97 -29.3 (93.56) 0.00 [ -0.28, 0.28 ]
6 Adherence to fiber intake at 6 months
Assuncao 2010 (2) 95 -0.6 (7.8) 97 1.1 (6.9) -0.23 [ -0.51, 0.05 ]
7 Adherence to sodium intake at 6 months
Assuncao 2010 95 33 (1063.38) 97 -371.5 (1109.97) 0.37 [ 0.09, 0.66 ]
8 Adherence to fruit intake at 6 months
Assuncao 2010 (3) 95 -3.7 (277.78) 97 52 (193) -0.23 [ -0.52, 0.05 ]
9 Adherence to vegetable intake at 6 months
Assuncao 2010 (4) 95 -11.1 (48.73) 97 -12.1 (37.4) 0.02 [ -0.26, 0.31 ]
10 Adherence to sweet food intake at 6 months
Assuncao 2010 95 -11 (187.14) 97 -44.2 (125.08) 0.21 [ -0.08, 0.49 ]
11 Adherence to energy intake at 12 weeks
Grace 1996 5 -2995 (2139) 8 -3759 (2155) 0.33 [ -0.80, 1.46 ]
12 Adherence to fat intake at 12 weeks
Grace 1996 5 -12 (5) 8 -24 (6) 1.97 [ 0.53, 3.41 ]
-10 -5 0 5 10
Favours control Favours experimental
(1) To correct for differences in the direction of the scale, means of both groups were multiplied by -1.
(2) To correct for differences in the direction of the scale, means of both groups were multiplied by -1.
(3) To correct for differences in the direction of the scale, means of both groups were multiplied by -1.
(4) To correct for differences in the direction of the scale, means of both groups were multiplied by -1.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 119
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Analysis 2.1. Comparison 2 Multiple interventions versus control in diet adherence, Outcome 1 Continuous
data.
Review: Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults
Comparison: 2 Multiple interventions versus control in diet adherence
Outcome: 1 Continuous data
Study or subgroup Control Experimental
Std.
Mean
Difference
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 Adherence to sodium-restricted diet at 3 months
Arcand 2005 24 -0.26 (1.62) 23 -0.66 (1.28) 0.27 [ -0.31, 0.84 ]
2 Adherence to diet at 3 months
Gucciardi 2007 (1) 36 -0.2 (0.08) 25 -0.66 (0.15) 3.99 [ 3.10, 4.88 ]
3 Adherence to fluid-restricted diet at 1 month
Tsay 2003 (2) 31 0.03 (0.82) 31 -0.27 (0.78) 0.37 [ -0.13, 0.87 ]
4 Adherence to fluid-restricted diet at 3 months
Tsay 2003 31 -0.07 (0.86) 31 -0.6 (0.78) 0.64 [ 0.13, 1.15 ]
5 Adherence to fluid-restricted diet at 6 months
Tsay 2003 31 -0.06 (0.85) 31 -0.72 (0.71) 0.83 [ 0.31, 1.35 ]
6 Non-adherence to diet (days) at 7 weeks
Wong 2010 49 -0.4 (2.01) 49 -1.23 (2.29) 0.38 [ -0.02, 0.78 ]
7 Non-adherence to diet (days) at 13 weeks
Wong 2010 49 -0.57 (1.97) 49 -1.28 (2.12) 0.34 [ -0.05, 0.74 ]
8 Non-adherence to diet (degree) at 7 weeks
Wong 2010 49 -0.24 (1) 49 -0.59 (0.92) 0.36 [ -0.04, 0.76 ]
9 Non-adherence to diet (degree) at 13 weeks
Wong 2010 49 -0.46 (1) 49 -0.61 (0.92) 0.15 [ -0.24, 0.55 ]
10 Non-adherence to fluid-restricted diet (days) at 7 weeks
Wong 2010 49 0.08 (1.95) 49 -0.37 (1.9) 0.23 [ -0.17, 0.63 ]
11 Non-adherence to fluid-restricted diet (days) at 13 weeks
Wong 2010 49 -0.2 (1.81) 49 -0.66 (1.8) 0.25 [ -0.14, 0.65 ]
12 Non-adherence to fluid-restricted diet (degree) at 7 weeks
Wong 2010 49 -0.12 (0.91) 49 -0.3 (0.75) 0.21 [ -0.18, 0.61 ]
13 Non-adherence to fluid-restricted diet (degree) at 13 weeks
Wong 2010 49 -0.28 (0.95) 49 -0.47 (0.67) 0.23 [ -0.17, 0.63 ]
-10 -5 0 5 10
Favours control Favours experimental
(1) To correct for differences in the direction of the scale, means of both groups were multiplied by -1.
(2) In the article, the authors reported a significant group main effect when analysed with baseline mean weight gains as covariate.
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Analysis 2.2. Comparison 2 Multiple interventions versus control in diet adherence, Outcome 2
Dichotomous data.
Review: Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults
Comparison: 2 Multiple interventions versus control in diet adherence
Outcome: 2 Dichotomous data
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
1 Adherence to sodium-restricted diet at 18 months
Hyman 2007 10/77 7/74 1.37 [ 0.55, 3.42 ]
2 Adherence to fat intake at 3 months
Laitinen 1993 8/38 9/46 1.08 [ 0.46, 2.52 ]
3 Adherence to saturated fat intake at 3 months
Laitinen 1993 5/38 6/46 1.01 [ 0.33, 3.05 ]
4 Adherence to unsaturated fat intake at 3 months
Laitinen 1993 11/38 9/46 1.48 [ 0.69, 3.19 ]
5 Adherence to carbohydrate intake at 3 months
Laitinen 1993 5/38 7/46 0.86 [ 0.30, 2.51 ]
6 Adherence cholesterol intake at 3 months
Laitinen 1993 23/38 28/46 0.99 [ 0.70, 1.41 ]
7 Adherence to saturated fat intake at 15 months
Laitinen 1993 14/38 3/46 5.65 [ 1.75, 18.21 ]
8 Adherence to fat intake at 15 months
Laitinen 1993 (1) 12/38 8/46 1.82 [ 0.83, 3.98 ]
9 Adherence to unsaturated fat intake at 15 months
Laitinen 1993 (2) 10/38 20/46 0.61 [ 0.32, 1.13 ]
10 Adherence to carbohydrate intake at 15 months
Laitinen 1993 11/38 10/46 1.33 [ 0.63, 2.79 ]
11 Adherence to fiber intake at 15 months
Laitinen 1993 2/38 0/46 6.03 [ 0.30, 121.82 ]
12 Adherence to cholesterol intake at 15 months
Laitinen 1993 25/38 33/46 0.92 [ 0.68, 1.23 ]
13 Adherence to phosphate-restricted diet at 3 months
Morey 2008 16/30 7/30 2.29 [ 1.10, 4.74 ]
14 Adherence to saturated fat intake at 1 year – CHD patients
Wood 2008 520/946 398/994 1.37 [ 1.25, 1.51 ]
15 Adherence to oily fish intake at 1 year – CHD patients
0.1 0.2 0.5 1 2 5 10
Favours control Favours experimental
(Continued . . . )
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(. . . Continued)
Study or subgroup Experimental Control Risk Ratio Risk Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Wood 2008 161/946 80/994 2.11 [ 1.64, 2.72 ]
16 Adherence to fish intake at 1 year – CHD patients
Wood 2008 747/946 666/994 1.18 [ 1.12, 1.24 ]
17 Adherence to fruit and vegetable intake at 1 year – CHD patients
Wood 2008 681/946 348/994 2.06 [ 1.87, 2.26 ]
18 Adherence to oily fish intake at 1 year – high risk CHD patients
Wood 2008 112/1019 60/1005 1.84 [ 1.36, 2.49 ]
19 Adherence to fish intake at 1 year – high-risk CHD patients
Wood 2008 846/1019 663/1005 1.26 [ 1.19, 1.33 ]
20 Adherence to fruit and vegetable intake at 1 year – high-risk CHD patients
Wood 2008 795/1019 392/1005 2.00 [ 1.84, 2.18 ]
21 Adherence to diet at 4 weeks
Zhao 2004 67/100 36/100 1.86 [ 1.39, 2.50 ]
22 Adherence to diet at 12 weeks
Zhao 2004 50/100 33/100 1.52 [ 1.08, 2.13 ]
0.1 0.2 0.5 1 2 5 10
Favours control Favours experimental
(1) In article, the authors reported a significant difference between groups.
(2) In article, the authors reported a significant difference between groups.
A D D I T I O N A L T A B L E S
Table 1. Summary of results: education
Study Intervention
group
(description)
Comparative group(s)
(description)
Effects on adherence No of studies
(no of participants
Quality
of the evidence
Favours (GRADE)
intervention
group
Favours
comparative
group
No difference
Telephone follow-up 4 (283)

Very low 2,4
In summary, among studies using a control/usual care group, three out of ten diet adherence
outcomes favoured the intervention group compared to control group and seven diet adherence
outcomes had no significant difference between groups. However, these three diet adherence out-
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 122
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Table 1. Summary of results: education (Continued)
comes favouring the intervention group were no longer significant at a later time point.
Chiu
2010
Telephone
followup
Control Adherence to sodium-restricted
diet, fat, fruit
and vegetable intakes at 8
weeks
Cummings
1981
Telephone
followup
Control;
Interventions:
(1) contract;
(2) contract with the involvement
of a family
member or friend
vs control:
Adherence
to potassiumrestricted
diet
and fluidrestricted
diet at 6
weeks
vs control: Adherence to
potassium-restricted diet
and fluid-restricted diet at
3 months;
vs (1) (2)
: Adherence to potassiumrestricted
diet and fluid-restricted
diet at 6 weeks and
3 months
Racelis
1998
Telephone
followup
Control Adherence to diet
Stewart
2005
Telephone
followup
Control Adherence
to
sodiumrestricted
diet at 24
weeks
Adherence to sodium-restricted
diet at 36 weeks;
Non-adherence to alcohol
intake at 24 and 36 weeks
Group sessions 2 (144)
Low 1,2
In summary, these studies did not allow us to draw conclusions on the effect of group sessions on
diet adherence outcomes.
Gill
2010 *
Group
sessions
Control
Jones
1986
Group
sessions
Interventions:
(1) Group sessions and
teach to use prompts/
cues;
(2) Individual sessions
with a dietitian;
(3) Individual sessions
with a dietitian and
teach to use prompts/
cues
vs (1) (2) (3): Adherence to
diet at 16 weeks
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Table 1. Summary of results: education (Continued)
Individual sessions with a dietitian 2 (203)
Low 1,2
In summary, these studies did not allow us to draw conclusions on the effect of individual sessions
with a dietitian on diet adherence outcomes.
Jones
1986
Individual
sessions
with a
dietitian
Interventions:
(1) Group sessions and
teach to use prompts/
cues;
(2) Individual sessions
with a dietitian;
(3) Individual sessions
with a dietitian and
teach to use prompts/
cues
vs (1) (2) (3): Adherence to
diet at 16 weeks
Micco
2007 *
Individual
sessions
with a
dietitian
Control
Individual sessions with a nurse 1 (81)

Very low
1,2,3
In summary, this study did not allow us to draw conclusions on the effect of individual sessions
with a nurse on diet adherence outcomes.
Hsueh
2007
Individual sessions
with a nurse
Intervention:
telephone
followup
and individual
sessions
with a
nurse
Adherence
to fiber, vegetable
and
fruit intakes
at 3 and 6
months
Educational tools-video 3 (318)

Moderate 1
In summary, among studies using a control/usual care group, two out of three diet adherence
outcomes favoured the intervention group compared to the control/usual care group and one diet
adherence outcome had no significant difference between groups. However, one out of two diet
adherence outcomes favouring the intervention group was no longer significant at a later time
point.
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Table 1. Summary of results: education (Continued)
Baraz
2010
Educational
tools –
video
Intervention: group sessions
and educational
tools – booklet
Adherence to diet and
fluid-restricted diet at 2
months
Mahler
1999
Educational
tools –
video
Control;
Intervention:
(1) video
and relapse prevention/
coping planning
vs control:
Adherence
to cholesterol
and saturated
fatrestricted
diet at 1
month
vs control: Adherence to
cholesterol and saturated
fat-restricted diet at 3
months;
vs (1)
: Adherence to cholesterol
and saturated fat-restricted
diet at 1 and 3 months;
McCulloch
1983
Educational
tools –
video
Usual care;
Intervention:
(1) nutritional tool
vs usual
care: Adherence
to day to
day consistency
in carbohydrate
intake at
6 months
vs (1): Adherence to day to
day consistency in carbohydrate
intake at 6months
Educational tools-booklet 1 (83)

Very low
,2,3,4
In summary, this study did not allow us to draw conclusions on the effect of booklet on diet
adherence outcomes.
Kendall
1987
Educational
tools –
booklet
Intervention:
nutritional tool
Adherence to energy, protein,
vitamin A, vitamin C,
thiamin, riboflavin, niacin,
calcium, phosphorus, iron,
zinc intakes at 3 and 6
months
*The authors did not report measures of adherence for both groups, making comparison between groups impossible.
GRADE – Factors decreasing the quality level of a body of evidence:
1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
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Table 2. Summary of results: persuasion
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
Favours intervention
group
Favours comparative
group
No difference
Reminders 2 (248)

Moderate 1
In summary, among studies using a control/usual care group, 3 out of 19 diet adherence
outcomes had no significant difference between groups. It was impossible to assess this result
for 16 diet adherence outcomes since data and/or statistical analyses needed for comparison
between groups were not provided.
Gans 1994 Reminder –
client
Usual care Adherence
to diet at
3 months
Gans 1994 Reminder –
physician
Usual care Adherence
to diet at
3 months
Gans 1994 Reminder
– client
and physician
Usual care Adherence
to diet at
3 months
Ryan 2002 * Reminder – 2
weeks, 3 and 6
months
Control
Ryan 2002 * Reminder – 3
and 6 months
Control
*The authors did not report measures of adherence for both groups, making comparison between groups impossible.
GRADE – Factors decreasing the quality level of a body of evidence:
1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
Table 3. Summary of results: incentivisation
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
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Table 3. Summary of results: incentivisation (Continued)
Favours
intervention
group
Favours comparative
group
No difference
Contracts with rewards 1 (116)
Low 1,3
In summary, among studies using a control/usual care group, two out of four diet adherence
outcomes favoured the intervention group compared to the control group and two diet adherence
outcomes had no significant difference between groups. However, these two diet adherence
outcomes favouring the intervention group were no longer significant at three months.
Cummings
1981
Contract Control;
Interventions:
(1) telephone
follow-up;
(2) contract
with the involvement
of
a family member
or friend
vs control: Adherence
to potassiumrestricted
diet and fluidrestricted
diet
at 6 weeks
vs control: Adherence
to potassiumrestricted
diet and fluidrestricted
diet
at 3 months;
vs (1) (2): Adherence
to potassiumrestricted
diet and fluidrestricted
diet
at 6 weeks and
3 months
GRADE – Factors decreasing the quality level of a body of evidence:
1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
Table 4. Summary of results: training
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
Favours
intervention
group
Favours comparative
group
No difference
Feedback 3 (661)
Low 4
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Table 4. Summary of results: training (Continued)
In summary, among studies using a control/usual care group, one out of seven diet adherence
outcomes favoured the intervention group compared to the control/usual care group, four
favoured the control group whereas two had no significant difference between groups.
Beasley 2008 Feedback Control Adherence
to energy,
fat, saturated
fat and
cholesterol intakes
at 4
weeks
French 2008 Feedback – less
intensive
Usual care Adherence
to general
diet and specific
diet at 12
months
French 2008 Feedback –
most intensive
Usual care Adherence
to general
diet and specific
diet at 12
months
Meland 1994 Feedback Control Adherence to
sodiumrestricted
diet
at 1 and 3
months
GRADE – Factors decreasing the quality level of a body of evidence:
1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
Table 5. Summary of results: restriction
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
Favours
intervention
group
Favours comparative
group
No difference
Restriction 1 (7)

Very low1,2,3
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Table 5. Summary of results: restriction (Continued)
In summary, this study did not allow us to draw conclusions on the effect of restriction on
diet adherence outcomes.
Conrad 2000* Restriction Control Adherence to
very
low fat diet at
7 months
*The authors did not report measures of adherence for both groups, making comparison between groups impossible.
GRADE – Factors decreasing the quality level of a body of evidence:
1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
Table 6. Summary of results: modelling
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
Favours
intervention
group
Favours comparative
group
No difference
Nutritional tools 7 (514)

Very low2,4
In summary, among studies using a control/usual care group, 3 out of 17 diet adherence
outcomes favoured the intervention group and 11 diet adherence outcomes had no significant
difference between groups. It was impossible to assess this result for three diet adherence
outcomes as data and/or statistical analyses needed for comparison between groups were not
provided.
Assuncao
2010
Nutritional
tools
Usual care Adherence to
sodium at 6
months
Adherence
to energy,
protein,
fat, carbohydrate,
cholesterol,
fiber,
fruit,
vegetable and
sweet
food intakes at
6 months
Chen 2006 Nutritional
tools
Control Adherence to
protein intake
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Table 6. Summary of results: modelling (Continued)
at 1 month
Grace 1996 Nutritional
tools
Control Adherence to
fat intakes at
12 weeks
Adherence to
energy at 12
weeks
Kendall 1987 Nutritional
tools
Intervention:
educational
tool –
booklet
Adherence
to energy,
protein, vitamin
and mineral
intakes
at 3 and
6 months
Logan 2010 Nutritional
tools
Intervention:
Barrier identification/
problem solving
and goal
setting
Adherence to
Mediterranean
diet at
6 and 12
months
McCulloch
1983
Nutritional
tools
Usual care;
Intervention:
(1) educational
tool –
video
vs control and
(1): Adherence
to day
to day consistency
in carbohydrate
intake at
6 months
Scisney-
Matlock
2006*
Nutritional
tools
Control
*The authors did not report measures of adherence for both groups, making comparison between groups impossible.
GRADE – Factors decreasing the quality level of a body of evidence:
1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
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Table 7. Summary of results: enablement
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
Favours
intervention
group
Favours comparative
group
No
difference
Behaviour change techniques 3 (136)
Very low2,4
In summary, only one study used a control group and three out of three diet adherence
outcomes had no difference between groups.
Aldarondo
1999
Barrier identification/
problem solving
and selftalk
Control Adherence
to energy, fat
and saturated
fat intakes at
14 weeks
Bennett 1986 Teach to use
prompts/cues
Interventions:
(1) self-talk;
(2) barrier
identification/
problem
solving
vs (1) (2): Adherence
to energy
intake
between baseline
and 15
weeks
Bennett 1986 Self-talk Interventions:
(1) teach to
use prompts/
cue;
(2) barrier
identification/
problem
solving
vs (1): Adherence
to energy
intake between
baseline
and 15 weeks
vs (2): Adherence
to energy
intake between
baseline
and 15 weeks
Bennett 1986 Barrier identification/
problem
solving
Interventions:
(1) teach to
use prompts/
cue;
(2) self-talk
vs (1): Adherence
to energy
intake between
baseline
and 15 weeks
vs (2): Adherence
to energy
intake between
baseline
and 15 weeks
Logan 2010 Barrier identification/
problem solving
and goal
setting
Intervention:
Nutritional
tools
Adherence to
Mediterranean
diet at
6 and 12
months
GRADE – Factors decreasing the quality level of a body of evidence:
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 131
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1 Limitations in the design and implementation of available studies suggesting high likelihood of bias.
2 Indirectness of evidence
3 Imprecision of results
4 Downgraded by two levels due to important limitations in the design and implementation of available studies suggesting high
likelihood of bias.
Table 8. Summary of results: multiple interventions
Study Intervention
group
(description)
Comparative
group(s)
(description)
Effects on adherence No of studies
(no of participants)
Quality of the
evidence
(GRADE)
Favours
intervention
group
Favours comparative
group
No difference
Multiple interventions 18 (7700) **
In summary, among studies using a control/usual care group, 21 out of 56 diet adherence
outcomes favoured the intervention group whereas 32 diet adherence outcomes had no significant
difference between groups. It was impossible to assess this result for three diet adherence
outcomes as data and/or statistical analyses needed for comparison between groups were not
provided. However, 4 out of 21 diet adherence outcomes favouring the intervention group
was no longer significant at a later time point.
Arcand 2005 Individual sessions
with a
dietitian and
goal setting
Usual care Adherence
to sodium-restricted
diet at
3 months
Baraz 2010 Intervention:
group sessions
and educational
tools –
booklet
Intervention:
educational
tools –
video
Adherence to
diet and fluidrestricted
diet
at 2 months
Becker 1998 Telephone follow-
up and
barrier identification/
problem
solving
Usual care Adherence
to fat-restricted
diet at
2 years
Blanson 2009 Motivational
interviewing
and self-monitoring
and feedbackdiary
Control Adherence to
diet at 28 days
Cummings
1981
Contract with
the involve-
Control;
Interventions:
vs control: Adherence
vs control: Adherence
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Table 8. Summary of results: multiple interventions (Continued)
ment of a family
member or
friend
(1) telephone
followup;
(2)
contract
to potassiumrestricted
diet and fluidrestricted
diet
at 6 weeks
to potassiumrestricted
diet and fluidrestricted
diet
at 3 months;
vs (1) (2): Adherence
to potassiumrestricted
diet
and fluid-restricted
diet at
3months
Gucciardi
2007
Group
sessions,
nutritional
tools and barrier
identification/
problem
solving
Control Adherence
to diet at
3 months
Hsueh 2007 Telephone follow-
up
and individual
sessions with a
nurse
Intervention:
Individual
sessions
with a nurse
Adherence
to fiber,
vegetable and
fruit
intake at 3 and
6 months
Hyman 2007 Telephone followup
and motivational
interviewing
– simultaneous
Usual care;
Intervention:
(1) telephone
followup
and motivational
interviewing
– sequential
vs usual care
and (1): Adherence
to sodium-restricted
diet at
6 months
vs usual care
and (1): Adherence
to
sodium-restricted
diet at
18 months
Hyman 2007 Telephone followup
and motivational
interviewing
– sequential
Usual care;
Intervention:
(1) telephone
followup
and motivational
interviewing
– simultaneous
vs (1): Adherence
to sodium-restricted
diet at
6 months
vs control: Adherence
to sodium-restricted
diet at
6 months and
18 months;
vs (1): Adherence
to sodium-restricted
diet at
18 months
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Table 8. Summary of results: multiple interventions (Continued)
Jiang 2004 Individual sessions
with
a nurse, telephone
followup
and goal
setting
Usual care Adherence to
ATP step II
diet at 3 and 6
months.
Jones 1986 Group
sessions and
teach to use
prompts/cues
Interventions:
(1) group sessions;
(2) individual
sessions with a
dietitian;
(3) individual
sessions with
a dietitian and
teach to use
prompts/cues
vs (1)
(2) (3): adherence
to diet at
16 weeks
Jones 1986 Individual sessions
with a
dietitian and
teach to use
prompts/cues
Interventions:
(1) group sessions;
(2) individual
sessions with a
dietitian;
(3) group sessions
and
teach to use
prompts/cues
vs (1)
(2) (3): adherence
to diet at
16 weeks
Laitinen 1993 Individual sessions
with a
dietitian, nutritional
tools
and goal setting
Usual care Adherence to
saturated
fat intakes at
15 months
Adherence to
saturated fat
intakes at 3
months; Adherence
to total
fat, unsaturated
fat, carbohydrate,
fiber and
cholesterol intakes
at 3 and
15months
Mahler 1999 Educational
tools
– video and relapse
prevention/
coping
planning
Control;
Intervention:
(1) educational
tools –
video
vs control: Adherence
to cholesterol
and saturated
fat-restricted
diet at
vs control: Adherence
to cholesterol
and saturated
fat-
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Table 8. Summary of results: multiple interventions (Continued)
1 month restricted diet
at 3 months;
vs (1): Adherence
to cholesterol
and saturated
fat –
restricted diet
at 1 and 3
months
Miller 1988 Individual sessions
with a
nurse and barrier
identification/
problem solving
and goal
setting
Control Adherence to
diet at 2 years
Adherence to
diet at 30 days,
60 days and 1
year
Morey 2008 Individual sessions
with a
dietitian, educational
toolsbooklet,
reminders,
motivational
interviewing
Control Adherence
to phosphaterestricted
diet
at 3 months
Tsay 2003 Self-monitoring
and feedback-
diary,
stress management
and goal
setting
Usual care Adherence to
fluid-restricted
diet at
3 months and
6 months
Adherence
to fluidrestricted
diet
at 1 month
Wong 2010 Telephone follow-
up and
goal setting
Control Nonadherence
to
diet (days and
degree) at 7
weeks and 13
weeks
Non-adherence
to fluidrestricted
diet
(days and degree)
at 7 weeks and
13 weeks
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Table 8. Summary of results: multiple interventions (Continued)
Wood 2008 –
coronary heart
disease
Individual sessions
with a
nurse and motivational
interviewing
Usual care Adherence to
saturated fat,
oily fish, fish
and fruit and
vegetable intakes
at 1 year
Wood 2008 –
high risk of
coronary heart
disease
Individual sessions
with a
nurse and motivational
interviewing
Usual care Adherence to
oily fish, fish
and fruit and
vegetables intakes
at 1 year
Zhao 2004 Telephone follow-
up, individual
sessions
with a dietitian
and goal
setting
Usual care High adherence
to diet
at 4 and 12
weeks
**Multiple interventions included a variety of interventions, which did not allow the use of GRADE.
A P P E N D I C E S
Appendix 1. PubMed search strategy
#1 Patient compliance[MH:NOEXP]
#2 Complian*[TIAB] OR Comply*[TIAB] OR Complied[TIAB] OR Adher*[TIAB] OR Noncomplian*[TIAB] OR Nonadher*[
TIAB]
#3 #1 OR #2
#4 Diet[MH]
#5 Diet therapy[MH]
#6 Nutrition assessment[MH]
#7 Food habits[MH]
#8 Nutrition policy[MH]
#9 Nutritional requirements[MH]
#10 Nutrition therapy[MH:NOEXP]
#11 Diet therapy[SH]
#12 Diet[TIAB] OR Diets[TIAB] OR Dieta*[TIAB] OR Diete*[TIAB] OR Dieti*[TIAB] OR Nutrition*[TIAB] OR Food
habit*[TIAB] OR Feeding behaviour*[TIAB] OR Eating behaviour*[TIAB]
#13 #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12
#14 Randomized controlled trial[PT]
#15 Controlled clinical trial[PT]
#16 Randomized[TIAB]
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 136
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#17 Randomly[TIAB]
#18 Trial[TIAB]
#19 Groups[TIAB]
#20 Placebo[TIAB]
#21 Drug therapy[SH]
#22 #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21
#23 Animals[MH] NOT Humans[MH]
#24 (#3 AND #13 AND #22) NOT #23
Appendix 2. EMBASE search strategy
#1 ’Patient compliance’/de
#2 (Complian* OR Comply* OR Complied OR Adher* OR Noncomplian* OR Nonadher*):ti,ab
#3 #1 OR #2
#4 Diet/exp
#5 ’Diet therapy’/exp
#6 ’Nutritional assessment’/de
#7 ’Feeding behavior’/exp
#8 ’Nutritional requirement’/exp
#9 #4 OR #5 OR #6 OR #7 OR #8
#10 (Diet* OR Nutrition* OR ’Food habit’ OR ’Food habits’ OR ’Feeding behavior’ OR ’Feeding behaviors’ OR ’Eating behavior’
OR ’Eating behaviors’):ti,ab
#11 #9 OR #10
#12 #3 AND #11
#13 ’Randomized controlled trial’/de
#14 ’Controlled clinical trial’/de
#15 ’Single blind procedure’/de OR ’Double blind procedure’/de
#16 ’Crossover procedure’/
#17 Random*:ti,ab
#18 Placebo*:ti,ab
#19 ((singl* or doubl*) adj (blind* or mask*)):ti,ab
#20 (crossover or ’cross over’ or factorial* or ’latin square’):ti,ab
#21 (assign* or allocat* or volunteer*):ti,ab
#22 #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21
#23 (Animal/ OR Nonhuman) NOT Human/
#24 #22 NOT #23
#25 #12 AND #24
Appendix 3. CINAHL search strategy
S1 MH “Patient Compliance”
S2 TI (Complian* OR Comply* OR Complied OR Adher* OR Noncomplian* OR Nonadher*) OR AB (Complian* OR Comply*
OR Complied OR Adher* OR Noncomplian* OR Nonadher*)
S3 S1 OR S2
S4 MH “Diet+”
S5 MH “Diet therapy+”
S6 MH “Nutritional assessment”
S7 MH “Food habits”
S8 MH “Eating behavior+”
S9 MH “Nutrition policy+”
S10 MH “Nutritional requirement+”
S11 MW “DH”
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 137
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S12 TI (Diet* OR Nutrition* OR “Food habit*” OR “Feeding behavior*” OR “Eating behavior*”) OR AB (Diet* OR Dieti* OR
Nutrition* OR “Food habit*” OR “Feeding behavior*” OR “Eating behavior*”)
S13 S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12
S14 S2 AND S13
S15 Randomi?ed controlled Trial*
S16 PT “Clinical Trial”
S17 MH “Clinical Trials +”
S18 MH “Random Assignment”
S19 MH “Placebos”
S20 MH “Quantitative studies”
S21 TI (random* OR trial or groups or placebo*) OR AB (random* OR trial or groups or placebo*)
S22 TI (singl* or doubl* or tripl* or trebl*) and TI (blind* or mask*)
S23 AB (singl* or doubl* or tripl* or trebl*) and AB (blind* or mask*)
S24 S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23
S25 S14 AND S24
S26 S25 (Limiters – Exclude Medline records)
Appendix 4. PsycINFO search strategy
#1 (complian* or comply* or complied or adher* or noncomplian* or nonadheren*)
#2 (diet* or nutrition* or “food habit” or “food habits” or “food intake” or “food intakes” or “eating behavior” or “eating behaviors”
OR “feeding behavior” OR “feeding behaviors”).
#3 #1 AND #2
#4 Random*
#5 Trial*
#6 Control*
#7 Placebo*
#8 ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*))
#9 “cross over” or crossover or factorial* or “latin square”
#10 assign* or allocat* or volunteer*
#11 it = “treatment effectiveness evaluation”
#12 it = “mental health program evaluation”
#13 it = “Experimental design”
#14 #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13
#15 #3 AND #14
Appendix 5. The Cochrane Library search strategy
#1 (Complian* OR Comply* OR Complied OR Adher* OR Noncomplian* OR Nonadher*):ti,ab,kw
#2 (Diet* OR Nutrition* OR “Food habit*” OR “Feeding behavior*” OR “Eating behavior*”):ti,ab,kw
#3 MeSH descriptor Diet explode all trees
#4 MeSH descriptor Diet Therapy explode all trees
#5 #2 OR #3 OR #4
#6 #1 AND #5
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Appendix 6. Methods for potential application in future updates of the review
Unit of analysis issues
We will meta-analyse cluster RCTs with non-cluster RCTs after inflating the standard errors to account for clustering. If cluster RCTs
are included, we will request the intracluster correlation coefficient (ICC) from the study authors. If the ICC is not available, it will
be imputed with external estimates obtained from similar studies. The ICC will then be used to calculate the design effect in order to
obtain an inflated standard error that accounts for clustering by multiplying the standard error of the effect estimate (from an analysis
ignoring clustering) by the square root of the design effect. We will also perform sensitivity analyses to assess how sensitive results are
to reasonable changes in ICC imputation.
Dealing with missing data
Where data are missing, we will attempt to contact study authors.We will conduct an intention-to-treat (ITT) analysis where possible;
otherwise data will be analysed as reported. Loss to follow-up will be documented and assessed as a source of potential bias. We will
perform sensitivity analyses based on consideration of ’best-case’ and ’worst-case’ scenarios (CCCRG 2010; Gamble 2005). The ’bestcase’
scenario is that all missing outcomes in the experimental intervention group had good outcomes, and all those missing in the
control intervention group had poor outcomes; the ’worst-case’ scenario is the reverse.
Assessment of heterogeneity
Where meta-analysis is possible, we will assess statistical heterogeneity between trials using the Chi2 statistic and I2 statistic. A Chi2 P
value of less than 0.10 or an I2 value equal to or more than 50%will be considered to indicate substantial heterogeneity. If heterogeneity
is identified, we will undertake subgroup analysis to investigate its possible source.We will conduct ameta-regression if there are enough
studies to assess the effect of the possible sources of heterogeneity.
Data synthesis
We will group data with respect to participants’ health condition (prevention versus management of chronic diseases). We will analyse
included studies to determine whether there are studies sufficiently similar in participants’ characteristics (e.g. age, gender), study design
(RCT, cluster RCT), type of intervention (e.g. directed towards client, family or non-family caregiver), environmental setting (e.g.
outpatient, workplace, or other community settings), and outcome measurement to allow for a meta-analysis of their combined data.
If studies are sufficiently similar, we will conduct meta-analyses using a random-effects model. If studies are too heterogeneous, we will
present a descriptive review of included studies using a narrative along with extracted data in tables and figures.
Subgroup analysis and investigation of heterogeneity
If enough studies are found to justify subgroup analyses, the following subgroups could be investigated using random-effects metaregression:
• Type of intervention (e.g. directed towards client, family or non-family caregiver); and
• Characteristics of participants (e.g. age, gender, socioeconomic status, immigrant status).
Sensitivity analysis
We will conduct a primary analysis with studies which we consider to have a low risk of bias (i.e. those receiving a ’low risk’ rating for
the criteria of sequence generation and allocation concealment). Sensitivity analyses will also be performed with all included studies in
order to show how conclusions might be affected if studies at high risk of bias were appropriate in order to explore the influence of the
following factors on effect size:
• excluding unpublished studies;
• excluding studies that do not provide the drop out rate;
• excluding any large studies to establish how they impact on the results;
• excluding studies using the following filters; language of publication, source of funding (industry versus other);
• excluding studies based on weak-evidence advice (e.g. not coming from practice guidelines).
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 139
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C O N T R I B U T I O N S O F A U T H O R S
SD coordinated and contributed to all stages of the review.
AL performed the search strategy, identified eligible studies, extracted data, performed analysis and interpreted result and wrote the
first draft of the review.
ST assisted with statistical analyses, contributed to the writing of the review.
SR developed the search strategy, contributed to the writing of the review.
KG contributed to the protocol development and to the writing of the review.
FL contributed to the protocol development and to the writing of the review.
D E C L A R A T I O N S O F I N T E R E S T
None known.
S O U R C E S O F S U P P O R T
Internal sources
• No sources of support supplied
External sources
• Canadian Institutes of Health Research, Canada.
Salary of Annie Lapointe
D I F F E R E N C E S B E TWE E N P R O T O C O L A N D R E V I EW
The protocol was published in 2010 (Desroches 2010).
Types of interventions: Multiple interventions are now defined as those with two or more interventions.
Pubmed search strategy: Food habit*[TIAB] or Feeding behaviour*[TIAB] or Eating behaviour*[TIAB] were added to the Pubmed
search strategy.
Assessment of reporting biases: publication bias using funnel plot was not explored since multiple adherence outcome measures were
reported in several studies and could not be pooled together.
Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults (Review) 140
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I N D E X T E R M S
Medical Subject Headings (MeSH)
∗Patient Compliance; Chronic Disease [prevention & control; ∗therapy]; Counseling [methods]; Diet Therapy [methods]; Dietetics
[∗methods]; Health Education [methods]; Randomized Controlled Trials as Topic
MeSH check words
Adult; Humans
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