4. Discussion
automaticity, malnutrition
MALNUTRITION
Despite the need for novel, theory-based dietary interventions for older adults following oral rehabilitation, the utility of habit formation as a means of facilitating healthy dietary behaviours had not previously been applied to this population. This pilot RCT compared habit strength between intervention and control groups for three novel, planned dietary behaviours in older adults who had previously undergone oral rehabilitation. The mean change in automaticity scores for all three generic dietary behaviours (as measured by SRBAI) were consistently higher within the intervention group compared to the control group at 6 weeks, 4 months (primary end point) and 8 months. This suggests that participants’ self-reported increases in enacting healthy planned dietary behaviours with less conscious awareness (greater automaticity) in the areas of FV, fibre and healthy protein intake. For the intervention group, all three specific, planned healthy behaviours became substantially more habitual over the course of the intervention, as manifested by significantly higher automaticity scores from baseline to 6 weeks onwards. Following the principles of habit formation, i.e., repetition within the same context/in response to the same cue, the planned behaviours became increasingly automatic, in line with previous habit literature and showed the ability for older people to demonstrate healthy dietary behaviour change [Across all three planned healthy behaviours, associations between automaticity and self-reported behavioural frequency were evident (i.e., self-reported adherence to carrying out the planned ‘healthy habit’). These measures can be considered predictors of one another; however, research suggests that although repetition (of the behaviour) is required for habits to develop, automaticity should be considered as a mental construct (lack of awareness, etc.), and more than just frequency of occurrence [Research has shown that habit behaviour effects are mostly attributable to habitual instigation, and not execution, and forming habits for both instigating and executing a behaviour may help maximise the likelihood of maintenance for certain behaviours [A number of BCTs were included in the intervention to support healthy planned dietary behaviour changes during the habit acquisition phase. These BCTs including problem solving, use of follow-up prompts and goal setting (outcomes), have been used in other similar dietary intervention studies involving older adults, and appear to enhance the effectiveness of such interventions [Previous qualitative research with older adults in the domain of physical activity showed that successful long-term users of wearable activity trackers typically described starting with a small behavioural goal and gradually increasing it, and action planning and coping planning strategies were evident [Some improvements in nutrient intakes in the intervention group were observed during this study. However, when compared with the control group, the intervention group only had a significantly higher mean change in potassium from baseline to 6 weeks, despite protein and fibre approaching significance at this time point indicating positive trends. Similarly, calcium showed a positive trend between groups at 8 months (non-significant), and increases in the intervention group may have been explained in part by many participants choosing to increase their milk intake as part of the healthy protein habit. The change in total MNA score from baseline to 6 weeks, however, was greater in the intervention group compared with the control group. It is important to consider that this is a pilot study and therefore the sample size may have been too small to detect a significant difference between groups for some of the outcomes such as dietary intake. Furthermore, despite these significant improvements in total MNA in the intervention group relative to the control group, it was questioned if the MNA was a valid tool for assessing malnutrition or truly captured nutritional change amongst the community dwelling older people of this study, despite it being the most recognised nutrition screening tool currently available [There are several strengths to this study, including the use of a theory-based intervention with a robust RCT method at a single site. This study is believed to be the first of its kind to follow the MRC guidelines for developing complex interventions within oral rehabilitation research and is one of a small number of nutrition studies that accounts for oral health in this population. There are a number of limitations to this research as well, including the use of a self-reported habit automaticity measure. It is debated whether individuals have sufficient ability to accurately self-report on habit strength when it requires reflection upon a non-reflective process [Differential attrition was noted between the intervention and control groups, with Certain groups within the older adult population may have been under-represented, such as ethnic minorities (a predominantly White population engaged), those with a low BMI, and those from deprived backgrounds (discussed further below). Unfortunately, this may limit the representativeness of the pilot RCT findings to the general population beyond Northern Ireland; despite closely reflecting the ethnicity profile of Northern Ireland within the UK (with 96.6% of the population classified as White in the 2021 census [Considerations for future research arising from this pilot study relate to the family structure and living arrangements of the participants, which can directly influence responsibility for food/dietary choices. Participants in this study were asked about living status (i.e., they needed to be free-living, not residing in a care facility) and they were only included if they agreed that they could influence the types of foods bought and eaten within their household as the intervention involved working directly with them on a one-to-one basis. Previous research has shown the importance of social support as a behaviour change technique for increasing FV intake via dietary interventions [