Appetite 151 (2020) 104682

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Appetite
journal homepage: www.elsevier.com/locate/appet

Does misperception of fruit and vegetable intake adequacy affect T

progression through the stages of behavior change after nutritional
intervention?
Maria Cecília Ramos de Carvalhoa, Mariana Carvalho de Menezesb, Natacha Toralc,
Aline Cristine Souza Lopesd,∗
a
Universidade Federal de Minas Gerais, Grupo de Pesquisa de Intervenções em Nutrição, 190 Alfredo Balena Avenue, Nursing School, Room 316, Santa Efigênia, 30130-
100, Belo Horizonte, MG, Brazil
b
Universidade Federal de Ouro Preto, Escola de Nutrição, Departamento de Nutrição Clínica e Social, Programa de Pós-Graduação em Saúde e Nutrição, Grupo de Pesquisa
de Intervenções em Nutrição, Dois Street, Morro do Cruzeiro Campus, Nutrition School, Room 65, 35400-000, Ouro Preto, MG, Brazil
c
Universidade de Brasilia, Faculdade de Ciências da Saúde, Departamento de Nutrição, Programa de Pós-Graduação em Nutrição Humana, Darcy Ribeiro Campus, Health
Sciences School, 70910-900, Brasília (North Wing), DF, Brazil
d
Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Nutrição, Programa de Pós-Graduação em Nutrição e Saúde, Grupo de Pesquisa de
Intervenções em Nutrição, 190 Alfredo Balena Avenue, Nursing School, Room 316, Santa Efigênia, 30130-100, Belo Horizonte, MG, Brazil

A R T I C LE I N FO A B S T R A C T

Keywords: Pseudomaintenance (PM) is a Transtheoretical Model (TTM) stage of change that refers to individuals who
Biobehavioral sciences believe they eat enough fruit and vegetables (FV) despite their low FV intake. It is not known how they change
Clinical trial behavior after usual TTM-based interventions. Thus, this randomized controlled community trial describes the
Feeding behavior effect of PM on progression through the stages of change for FV intake among adult and elderly health promotion
Food and nutrition education
service users after TTM-based intervention. The stage of change for FV intake was assessed; FV intake was
Fruit
Vegetables
estimated from brief validated questions at baseline (n = 3414) and follow-up (n = 1782). Individuals whose
perception of adequacy matched the estimated intake were labeled as “concordant perception,” while those with
low intake who believed that their intake was adequate were classified as being in PM. The intervention group
received the intervention while the control group received usual care. The prevalence of “no stage progression”
at follow-up was close to 50% for those in PM at baseline. After adjustment for demographics, randomization,
self-efficacy, decisional balance, and baseline intake, users in PM at baseline had higher odds [OR = 1.53
(1.21–1.94)] of progressing to higher stages for fruit and no difference in progression for vegetables. We propose
strategies to approach FV intake in future studies and reinforce the need for additional trials aimed at describing
changes in FV intake among individuals in PM, in order to continue answering the scientific questions that we
began to investigate.

1. Introduction
Fruit and vegetable (FV) consumption promotes health (WHO &
FAO, 2005) and lowers the risk of morbidity and premature mortality
(Boeing et al., 2012); however, intake remains low worldwide. In
Brazil, only 23.7% of adults report eating at least five servings a day
(Brasil, 2019). In 2017, FV intake was found to be insufficient in almost
all regions of the world, and diets low in fruit (less than 250g/day) and
low in vegetables (less than 360g/day) were among the five leading
dietary risk factors for morbidity and mortality (Afshin et al., 2019).
Different interventions for improving dietary habits have been
proposed. The Transtheoretical Model (TTM) stands out as a promising
tool for health promotion and nutrition education, including increases
in FV intake (Menezes, Bedeschi, Santos, & Lopes, 2016). The TTM's
main pillar is called stages of change, which represent an individual's
readiness to modify a certain behavior (for example, to quit smoking or

Abbreviations: CG, control group; FV, fruit and vegetables; HAP, Health Academy Program; IG, intervention group; NRA, non-reflective action; PM, pseudo-
maintenance; TTM, Transtheoretical Model; WHO, World Health Organization
∗
Corresponding author. Nutrition Department. Nursing School of the Federal University of Minas Gerais, Brazil. 190 Alfredo Balena Avenue, room 316, Santa
Efigênia, 30130-100, Belo Horizonte, MG, Brazil.
E-mail addresses: ceciliaramosnutri@gmail.com (M.C.R.d. Carvalho), marysnut@gmail.com (M.C.d. Menezes), natachatoral@hotmail.com (N. Toral),
alinelopesenf@gmail.com (A.C.S. Lopes).

https://doi.org/10.1016/j.appet.2020.104682
Received 22 August 2019; Received in revised form 3 March 2020; Accepted 22 March 2020
Available online 28 March 2020
0195-6663/ © 2020 Elsevier Ltd. All rights reserved.
M.C.R.d. Carvalho, et al.
to increase fruit and vegetable intake) (J O Prochaska, Norcross, &
DiClemente, 2013). The other pillars are called self-efficacy, decisional
balance, and processes of change, which mediate the evolution through
the stages of change (J. O. Prochaska & Velicer, 1997).
The five traditional stages of change are called pre-contemplation,
contemplation, preparation, action, and maintenance. Individuals in
pre-contemplation are not ready to change the target behavior. Those in
contemplation are thinking about changing but feel ambivalent about
the pros and cons of changing. Individuals in preparation have decided
to start changing their behavior in the next 30 days. Those in action
have sustained change for up to six months, while those in maintenance
have been able to sustain the change for over six months (Prochaska,
Diclemente, & Norcross, 1992).
Stages of change can be measured for a variety of health-related
behaviors, such as dietary behavior (J O Prochaska et al., 2013). The
identification of an individual's stage of change results from assess-
ments based on individual perception of intake adequacy or estimated
food intake (J O Prochaska et al., 2013; Toral & Slater, 2009). However,
some individuals' perception of adequacy and objectively estimated
intake might not match. Thus, two additional stages of change have
been proposed: pseudomaintenance (PM), proposed by Steptoe et al. in
1996 (Steptoe, Wijetunge, Doherty, & Wardle, 1996) and non-reflective
action (NRA), proposed by Ma et al. in 2003 (Ma, Betts, Horacek,
Georgiou, & White, 2003). PM refers to individuals who have a low
intake of these foods but believe they eat enough FV (Steptoe et al.,
1996), while NRA refers to individuals who meet FV intake require-
ments but do not recognize their intake as sufficient (Ma et al., 2003).
To move from a stage of change to a more advanced stage, in-
dividuals change their self-efficacy and decisional balance (J. O.
Prochaska & Velicer, 1997). Self-efficacy represents the extent to which
individuals believe they are able to perform the behavior change, while
decisional balance means the relative importance given to the pros and
cons of changing (J. O. Prochaska & Velicer, 1997).
The existence of misperceived food intake has been reported in
different contexts (Bedeschi, Lopes, & Santos, 2016; Carvalho, Menezes,
& Lopes, 2018; Dijkstra, Neter, Brouwer, Huisman, & Visser, 2014;
Figueira, Lopes, & Modena, 2015; Lechner, Brug, & De Vries, 1997;
Lechner, Brug, De Vries, Van Assema, & Mudde, 1998; Ling & Horwath,
2000; Ma et al., 2003; Povey, Conner, Sparks, James, & Shepherd,
1998; Sproesser, Klusmann, Schupp, & Renner, 2015; Steptoe et al.,
1996; Toral & Slater, 2009; Toral, Slater, Cintra, & Fisberg, 2006).
However, few longitudinal or intervention studies have been done to
identify whether and how misperception of FV intake affects the evo-
lution of FV intake (Menezes, Mingoti, Mendonça, & Lopes, 2017;
WHO, 2004). Most studies have a cross-sectional (Bedeschi et al., 2016;
Carvalho et al., 2018; Dijkstra et al., 2014; Lechner et al., 1997, 1998;
Ling & Horwath, 2000; Ma et al., 2003; Steptoe et al., 1996; Toral et al.,
2006; Toral & Slater, 2009) or qualitative (Figueira et al., 2015; Povey
et al., 1998) design. PM is the most prevalent type of discordant per-
ception (Carvalho et al., 2018; Toral & Slater, 2009) and the one that
poses the greatest risk for individuals, as they are exposed to low intake
while believing that they eat enough FV; this can hinder their moti-
vation to increase their intake. Furthermore, it is not known whether
they can improve their perception of FV intake adequacy when they are
exposed to interventions based on the five traditional stages.
Thus, this study aims to describe the effect of baseline pseudo-
maintenance on the evolution of the stages of change for FV intake in a
sample of adult and elderly health promotion service users after a usual
TTM-based nutritional intervention.
2. Material and methods
2.1. Study design, setting, and sample
A randomized controlled community trial was carried out with a
sample of Health Academy Program (HAP) users in Belo Horizonte,
2
Appetite 151 (2020) 104682
Brazil. HAP centers are part of the Brazilian Unified Health System. In
Belo Horizonte, these public health promotion services are usually lo-
cated in vulnerable neighborhoods and offer free supervised physical
activity and health promotion actions for adults and seniors (A. C. S.
Lopes et al., 2016).
The trial was carried out according to the Declaration of Helsinki
guidelines and is recorded in the Brazilian Clinical Trials Registry under
protocol number RBR-9h7ckx. The study was approved by the
University (0537.0.203.000–11) and the City Hall
(0537.0.203.410–11A). Written informed consent was obtained from
all participants prior to data collection.
This trial was conducted using a random, representative sample of
HAP centers located in vulnerable neighborhoods, with 3763 eligible
users. Of the 50 existing HAP centers in the city in 2012, eight were
excluded from the sampling process because they were located in low-
vulnerability neighborhoods (i.e., affluent areas of the city) (n = 6) or
because they had participated in nutrition interventions two years be-
fore the trial (n = 2). Among the remaining 42 HAP centers, 18 were
randomly selected, stratified according to the city's nine administrative
districts. Units of randomization were the 18 HAP centers, which were
randomly allocated to intervention or control in a 1:1 ratio.
Eligibility criteria for the users in the 18 randomized HAP centers
included: being over 20 years old; frequently using the service; not
being pregnant; not having cognitive impairments; and providing
written informed consent. All HAP users who met eligibility criteria
were personally invited by the interviewers to answer the baseline
questionnaire. The physical educators at each HAP center also in-
tensified the invitations made by the research team. Data collection was
scheduled with each participant according to his or her preference,
within HAP operating hours. More information about the sampling
procedures is available elsewhere (Menezes, Diez Roux, & Lopes, 2018).
2.2. Data collection
Data were collected face-to-face by trained interviewers (nutrition
undergraduates, dietitians, and graduate students) at baseline and after
the intervention period. A field supervisor was designated for each HAP
center, and a Data Collection Handbook was available for interviewers
throughout the data collection period to ensure standardization
(Menezes, Costa, et al., 2017). Demographic data included sex, age, and
years of schooling.
Stages of change for FV intake (pre-contemplation, contemplation,
preparation, action, and maintenance) were assessed using an algo-
rithm proposed by Kristal et al. (Kristal, Glanz, Curry, & Patterson,
1999) and adapted in Brazil by Toral et al. (Toral et al., 2006). In-
dividuals were first asked about whether they perceived their intake as
adequate or inadequate. Those who perceived their intake as in-
adequate were asked about their intentions to increase it and about the
timeframe for the intended behavior change. Respondents who per-
ceived their intake as adequate were asked how long they had main-
tained such an intake. Separate algorithms were used for fruit and for
vegetables. The complete instrument for assessing the stages of change
can be found in Supplementary Material S1.
Following World Health Organization (WHO) guidelines, fruit and
vegetables were treated as separate groups (WHO & FAO, 2005). FV
intake was estimated using brief validated questions (Brasil, 2019; M. S.
Lopes, Santos, Lopes, & Abreu, 2017). These brief questions do not
estimate the intake of specific types of FV; instead, the instrument in-
vestigates the overall frequency of the intake of fruit and vegetables and
the usual number of servings (M. S. Lopes et al., 2017). Frequency of
intake was investigated for overall fruit, excluding fruit juices or
smoothies, and overall vegetables, excluding roots and tubers (i.e.,
cassava, potatoes, and yams). For example, frequency of vegetable in-
take was estimated using the following question: “How many times a
week do you usually eat at least one type of vegetable (excluding cassava,
potatoes, and yams)?“. Possible answers for frequency of intake were:
M.C.R.d. Carvalho, et al.
1–2 days a week, 3–4 days a week, 5–6 days a week, every day (in-
cluding Saturdays and Sundays), never, and almost never (1–3 times a
month). In addition, the number of servings was estimated with usual
measurements (pieces, slices, cups, tablespoons, bowls, or plates) to
allow for reliable answers. The complete instrument for assessing FV
intake can be found in Supplementary Material S2.
Interviewers were trained to convert these usual measurements to
servings, following standardized measurements that the research team
developed in an experimental kitchen. One piece or one slice of fruit
counted as one serving. One serving spoon or two tablespoons counted
as one serving of vegetables, except for raw leafy greens; for those, two
serving spoons or four tablespoons counted as one serving (M. S. Lopes
et al., 2017). Daily intake of at least three servings of fruit or two ser-
vings of vegetables was considered adequate consumption (WHO &
FAO, 2005). Individuals who did not meet these recommendations were
classified as insufficient consumers of fruit and/or vegetables (WHO &
FAO, 2005).
After stage assessment and intake estimation, stage reclassification
was carried out according to the agreement between the perception of
intake and the estimated intake. Responders who believed their intake
was adequate but who did not meet WHO guidelines were reclassified
as pseudomaintenance (Steptoe et al., 1996), while those who met the
intake requirements without recognizing it were reclassified as non-
reflective action (Ma et al., 2003). Individuals whose perception of
adequacy agreed with the estimated intake were collectively classified
as “concordant perception.”
Considering the consistently low prevalence of the non-reflective
action stage in the literature (Carvalho et al., 2018; Menezes, Mingoti,
et al., 2017) and its limited importance to public health and to research
(as these individuals already meet the recommended FV intake), par-
ticipants in this stage of change at baseline (n = 150; 6.7% for fruit and
n = 187; 8.4% for vegetables) were excluded from the analysis. In-
dividuals in this stage at follow-up (n = 102; 4.9% for fruit and n = 88;
4.3% for vegetables) were also excluded.
Self-efficacy and decisional balance were assessed using five-point
Likert-type scales, ranging from “not at all confident” (0 points) to
“completely confident” (4 points) or from “completely disagree” (0
points) to “completely agree” (4 points) (Mainvil, Lawson, Horwath,
McKenzie, & Hart, 2010; Mainvil, Lawson, Horwath, McKenzie, &
Reeder, 2009). Users reported their degree of confidence regarding four
self-efficacy affirmations (Bandura, 1977; Erinosho et al., 2012; Kidd &
Peters, 2010; Salehi, Mohammad, & Montazeri, 2011) and their level of
agreement with eight decisional balance affirmations (four pros and
four cons) (Kidd & Peters, 2010; Mainvil et al., 2010; Salehi et al.,
2011).
2.3. Nutritional intervention
During the intervention period (seven months), HAP centers in the
control group (CG) received usual care according to the routine prac-
tices of HAP centers. This usual care included collective physical ac-
tivity classes for an hour, three times a week, and collective nutrition
education lessons regarding healthy eating, with themes other than
fruit and vegetable intake (Menezes, Mendonça, Ferreira, Guimarães, &
Lopes, 2018).
In addition to usual care, HAP centers in the intervention group (IG)
received TTM-based intervention targeted at increasing FV intake,
carried out for seven months by a trained multidisciplinary team (die-
titians, educators, and psychologists). All members of the multi-
disciplinary team had experience in health promotion and food and
nutrition education, were additionally trained to standardize inter-
vention development, and received operational support from under-
graduate nutrition students (Mendonça, 2016).
The team and the intervention participants could not be blinded to
the randomization, as it was an educational intervention. Therefore,
both the team and the participants knew whether or not they were
3
Appetite 151 (2020) 104682
involved in the FV intervention.
Because usual TTM-based interventions allocate participants to the
intervention subgroups based on their initial stage classification (the
stage of change based on their perception of intake adequacy), this
procedure was carried out with all participants, including those in PM
or NRA at baseline. Therefore, participants were grouped in the fol-
lowing intervention subgroups: pre-action (pre-contemplation, con-
templation, or non-reflective action stages), preparation (preparation
stage), or action (action, maintenance or pseudomaintenance stages)
(Menezes, Mendonça, Ferreira, Guimarães, & Lopes, 2018).
Intervention was tailored to stages of change, while the appropriate
processes of change were employed to raise self-efficacy, improve de-
cisional balance, and facilitate stage progression (J O Prochaska et al.,
2013). Cognitive processes (consciousness raising, dramatic relief, en-
vironmental reevaluation, self-reevaluation, and social liberation) were
used during the intervention for the pre-action subgroup. The pre-
paration subgroup used a mix of cognitive and behavioral processes
(self-reevaluation, social liberation, and self-liberation). The action
subgroup used behavioral processes (social liberation, self-liberation,
contingency management, helping relationships, counter-conditioning,
and stimulus control) (Mendonça, 2016; J. O.; Prochaska & Velicer,
1997). Activities were aligned with national guidelines for health pro-
motion and food and nutrition education (Brasil, 2012). Pro-
blematizing-dialogic education, as proposed by Paulo Freire, was em-
ployed to promote participants’ autonomy and empowerment. This
theoretical framework from the field of education was combined with
the TTM principles to inform the planning and execution of meetings in
the intervention subgroups. We chose this theory because it is aligned
with the concept of health promotion and is recommended by the
Brazilian National Secretariat of Food and Nutrition Security in the
national guidelines for food and nutrition education (Brasil, 2012;
Freire, 2013).
Overall, 711 monthly meetings were carried out at the nine HAP
centers in the IG, given that each meeting was to have no more than 20
participants. Intervention methods used during the intervention were
workshops, interactive environment-based activities, the delivery of
informative materials and personalized motivational postcards, and
telephone calls. Each meeting had the following overall structure: in-
troduction of the topic and initial discussion; creation of strategies to
solve a central problem; and conclusion (Menezes, Mendonça, Ferreira,
Guimarães, & Lopes, 2018).
Common intervention themes for all groups (pre-action, prepara-
tion, and action) were the relationship between FV intake and health,
FV seasonality and cost, and techniques for preparing FV and preser-
ving nutritional and sensorial quality. Specific themes, tailored to each
group's needs, included health and self-care and the determinants of
food choice (pre-action), diversifying cooking methods for FV (pre-
paration), FV servings, and social support for eating FV (action). More
information about the intervention is available elsewhere (Menezes,
Mendonça, Ferreira, Guimarães, & Lopes, 2018).
2.4. Outcome variable
After intervention, IG and CG participants were reassessed re-
garding stage of change and estimated FV intake and were then re-
classified according to the agreement between the perception of intake
adequacy and the estimated FV intake (Ma et al., 2003; Steptoe et al.,
1996; WHO & FAO, 2005). Stage evolution was defined based on each
user's baseline and follow-up stage of change (Fig. 1).
2.5. Statistical analysis
Microsoft Access was used for tabulation and consistency analysis.
Stata 13.1 (StataCorp, College Station, Texas, United States of America)
was employed for further consistency analysis, sample description, and
multivariate analysis.
M.C.R.d. Carvalho, et al.
Fig. 1. Description of the criteria for classifying stage evolution according to baseline and follow-up stages of change. Belo Horizonte, Brazil, 2013–2014.
CG and IG users were compared at baseline regarding demographics
(sex, age, schooling) and stages of change for FV intake. A chi-square
test was used for categorical variables; numeric variables were com-
pared using a simple t-Student test (normal distribution) or Mann-
Whitney test (non-normal distribution), p-value < 0.05.
Individuals in PM at baseline were compared to those who were in
the other stages. Variables for comparison were sex (chi-square test),
age (simple t-Student test), schooling, and baseline FV intake (Mann-
Whitney test), p-value < 0.05.
Considering that being in pseudomaintenance is the most unfavor-
able situation for FV intake, it was not possible for individuals in this
stage of change at baseline to regress to an “earlier” stage of change.
Evolution through the stages of change was re-coded into a binary
variable for each food group, with categories “no progression (re-
gressed + remained)” and “progression.” Stage progression was com-
pared between individuals with concordant perception and PM at
baseline, stratified by randomization, by use of a chi-square test, p-
value < 0.05.
The effect of being in pseudomaintenance at baseline on stage
evolution for FV intake was identified by crude and adjusted logistic
regression models, considering that the outcome was the binary vari-
able “evolution through the stages of change” (categories: “no pro-
gression” and “progression”). The baseline perception of FV intake
adequacy was treated as the exposure (categories: “agreement between
perception and intake” and “pseudomaintenance”). Because fruit and
vegetables were treated as separate food groups, two models were ad-
justed. The outcome variables for both food groups had “no progression
through stages of change” as the reference category, while the other
category was “stage progression.”
4
Appetite 151 (2020) 104682
Progressive adjustment by demographics, randomization, one self-
efficacy component, one decisional balance component, and baseline
intake was carried out. Adjustment variables were chosen according to
plausibility, previous literature regarding TTM-based interventions for
FV intake, and baseline differences between CG and IG. Binary logistic
regression models were used as a means of bivariate analysis to test the
association between each adjustment variable and the outcomes
(Supplementary Material S4 and S5). At this stage, demographics (sex,
age, and schooling), randomization (CG or IG), psychosocial variables
(self-efficacy and decisional balance components), and baseline intake
(mean daily servings of fruit and vegetables) were tested. For self-effi-
cacy and decisional balance, components with p < 0.200 in the bi-
variate analysis were entered into hierarchical logistic regression
models to select the component with the strongest association with each
outcome (Supplementary Material S6 and S7). Model fit was assessed
using pseudo R2.
3. Results
At baseline, 3414 HAP users from the 18 HAP centers were eval-
uated (response rate: 90.7% of eligible HAP users; refusals: 3%,
n = 112; exclusion: 6.3%, n = 237) and randomized to the interven-
tion group (n = 9 HAP centers, 1483 users) or the control group (n = 9
HAP centers, 1931 users). After intervention, 2241 individuals were
reassessed (lost to follow-up: n = 1173, 34.4%). All individuals who
were reclassified in non-reflective action at baseline and/or follow-up
(n = 644) were excluded from the dataset (Fig. 2).
Most participants in the follow-up sample (n = 1782) were women,
middle-aged and with low schooling. CG and IG participants were
M.C.R.d. Carvalho, et al. Appetite 151 (2020) 104682

Fig. 2. CONSORT flow chart.

Table 1
Baseline characteristics of randomized controlled community trial participants. Belo Horizonte, Brazil, 2013–2014.
Characteristics Total (n = 1782) Control (n = 1018) Intervention (n = 764) P-value

a a a
n Values n Values n Values

Sex (%) 0.010b

Female 1538 86.3 897 88.1 641 83.9
Male 244 13.7 121 11.9 123 16.1
Age (years) 1782 58.1 ± 11.0 1018 57.9 ± 10.7 764 58.4 ± 11.4 0.321c
Years of schooling 1781 7.0 (4.0; 11.0) 1017 7.0 (4.0; 11.0) 764 5.0 (4.0; 11.0) 0.002d
Stages of change for fruit intake 0.486b
Pre-contemplation 81 4.6 42 4.1 39 5.1
Contemplation 127 7.1 71 7.0 56 7.3
Preparation 461 25.9 271 26.7 190 24.9
Action 25 1.4 14 1.4 11 1.4
Maintenance 596 33.5 353 34.7 243 31.8
Pseudomaintenance 490 27.5 265 26.1 225 29.5
Stages of change for vegetable intake 0.081b
Pre-contemplation 39 2.2 25 2.5 14 1.8
Contemplation 50 2.8 19 1.9 31 4.1
Preparation 189 10.6 109 10.7 80 10.5
Action 31 1.7 18 1.8 13 1.7
Maintenance 940 52.8 551 54.2 389 50.9
Pseudomaintenance 531 29.8 294 28.9 237 31.0
Daily fruit intake at baseline (servings) 1758 2.0 (1.0; 3.0) 1003 2.0 (1.0; 3.0) 755 2.0 (1.0; 3.0) 0.082d
Daily vegetable intake at baseline (servings) 1768 2.3 (1.5; 3.0) 1008 2.3 (1.5; 3.0) 760 2.3 (1.5; 3.0) 0.966d

Note.
a
Mean ± standard deviation, percentages, or median and P25–P75.
b
Chi-square test
c
Simple t-Student test
d
Mann-Whitney test.

different regarding sex and years of schooling at baseline (Table 1).
Those who were lost to follow-up (n = 988) were mostly women,
younger, with a higher mean educational attainment. They also differed
from follow-up respondents regarding stage of change but did not differ
from the final sample regarding fruit or vegetable intake
(Supplementary Material S3).
There was a high prevalence of pseudomaintenance for FV intake at
baseline, with approximately 27.5% of individuals in this stage for fruit
and 29.8% for vegetables (Table 1). Reclassification in PM was more
frequent among men than among women, for fruit (33.7% vs. 26.5%)
and for vegetables (35.4% vs. 29.0%) (chi-square test; p < 0.05).
Compared to individuals in the other stages, those in PM for fruit
intake at baseline were slightly older (mean: 59.1 vs. 57.7 years old),
had fewer years of schooling (median: 4.0 vs. 8.0), and ate fewer daily
servings of fruit (median: 1.6 vs. 2.4) (simple t-Student test and Mann-
Whitney test, p < 0.05).
Those in PM for vegetable intake at baseline had fewer years of
schooling (median: 5.0 vs. 7.0), and ate fewer daily servings of vege-
tables (median: 1.5 vs. 2.5) but did not differ in age from those in the
other stages (simple t-Student test and Mann-Whitney test, p < 0.05).

5
M.C.R.d. Carvalho, et al. Appetite 151 (2020) 104682

Table 2 among adults and seniors. Previous cross-sectional studies have shown
Stage progression for fruit and vegetable intake according to baseline percep- mixed results regarding misperceived FV intake, mostly with different
tion of intake adequacy. Belo Horizonte, Brazil, 2013–2014. prevalences (Bedeschi et al., 2016; Dijkstra et al., 2014; Lechner et al.,
Intervention group (n = 764) 1997, 1998; Ling & Horwath, 2000; Toral et al., 2006; Toral & Slater,
2009). Some of these studies have investigated FV as a single group
No progression Progression P-value (Bedeschi et al., 2016; Ling & Horwath, 2000) or in different popula-
tions (Bedeschi et al., 2016; Dijkstra et al., 2014; Lechner et al., 1997,
N % n %
1998; Ling & Horwath, 2000; Toral et al., 2006; Toral & Slater, 2009),
Baseline perception of fruit intake 0.132a and the authors used different methods for identifying misperception
Concordant perception b 250 46.5 288 53.5 (Dijkstra et al., 2014; Lechner et al., 1997, 1998; Ling & Horwath, 2000;
Pseudomaintenance 118 52.4 107 47.6
Toral et al., 2006). Therefore, a comparison between these findings is
No progression Progression P-value limited.
N % n % Some theories propose that misperception of diverse behaviors,
especially in the form of unrealistic optimism (which is similar to
Baseline perception of vegetable intake < 0.001a pseudomaintenance), will lead individuals to believe that they do not
Concordant perception b 199 37.8 328 62.2
Pseudomaintenance 125 52.7 112 47.3
need to perform any change. Thus, they will have reduced motivation
and intentions to modify general and food-specific behaviors (Ferrer &
Control group (n = 1.018) Klein, 2015; Shepherd, 2002; Shepperd, Klein, Waters, & Weinstein,
No progression Progression P-value 2013; Shepperd, Pogge, & Howell, 2017; Shepperd, Waters, Weinstein,
n % n %
& Klein, 2015). These overly optimistic individuals would pay less at-
Baseline perception of fruit intake 0.720a tention to health promotion messages, believing the messages apply
Concordant perception b 413 55.1 337 44.9 only to others and not to them, or would even refuse to take part in
Pseudomaintenance 142 53.8 122 46.2 health promotion activities; this explains part of the failure of many
health promotion messages (Ferrer & Klein, 2015; Miles & Scaife, 2003;
No progression Progression P-value
N % n %
Shepherd, 2002; Shepperd et al., 2013, 2015, 2017).
However, longitudinal studies evaluating the association between
Baseline perception of vegetable intake 0.017a initial misperception and the subsequent evolution of diverse health
Concordant perception b 278 38.5 444 61.5 behaviors have shown mixed findings (Shepperd et al., 2013, 2015,
Pseudomaintenance 137 46.6 157 53.4
2017). This situation raises the hypothesis that the direction of this
Note. association might be behavior-specific, i.e., unrealistic optimism can be
a
Chi-square test. either beneficial or negative depending on the behavior (Ferrer & Klein,
b
Concordant perception: individuals classified in pre-contemplation, con- 2015; Shepperd et al., 2013, 2015, 2017). This is consistent with our
templation, preparation, action, or maintenance. results, given that pseudomaintenance had different effects in the stage
progression for fruit intake (a positive effect) and for vegetable intake
Out of the 1782 individuals assessed at follow-up, 26.9% and 18.4% (no effect).
remained in the same stage for fruit intake and for vegetable intake, We hypothesized that, although the intervention was tailored to
respectively. Progression to a more advanced stage happened among individuals with a concordant perception, it could help those in pseu-
48.1% of individuals for fruit intake and among 58.5% of individuals domaintenance recognize the discordance between their perception and
for vegetable intake; meanwhile, 25.0% regressed to a lower stage for intake (Menezes, Mingoti, et al., 2017). Our results partially confirm
fruit, while 23.1% did the same for vegetables (data not shown). this hypothesis. Individuals in PM for vegetable intake at baseline had
Individuals in pseudomaintenance (IG and CG) for vegetable intake similar odds of stage progression as those with a concordant perception.
had lower prevalences of progression to more advanced stages of However, those in PM for fruit intake have shown higher odds of pro-
change when compared to those with a concordant perception. There gressing to higher stages of change. These findings also highlight the
was no difference in the prevalence of stage progression for fruit intake importance of evaluating fruit and vegetables separately, according to
according to pseudomaintenance (Table 2). the WHO guidelines (WHO & FAO, 2005), as the evolution of eating
In the logistic regression models, after adjustment for baseline in- behavior is different among them.
take, individuals in pseudomaintenance for fruit at baseline had sig- Although baseline pseudomaintenance was associated with stage
nificantly higher odds of progressing [1.53 (1.21–1.94)]. However, progression for fruit intake after adjustments, the final regression model
those in PM for vegetable intake did not show different odds of pro- had a weak pseudo R2 value. The final regression model of stage pro-
gressing when compared to those with a concordant perception [0.96 gression for vegetable intake also had a weak explanatory power and
(0.76–1.20)] (Fig. 3). did not show any associations between baseline pseudomaintenance
Regression models adjusted for demographics, randomization, self- and stage progression for vegetable intake.
efficacy, and decisional balance components and baseline intake ex- We highlight the fact that no additional results of experimental
plained 13.9% and 5.8% of the stage progression for fruit intake and for studies regarding the pseudomaintenance of FV intake were found. The
vegetable intake, respectively (Supplementary Material S8 and S9). scientific question that we started to investigate - “Does misperception of
fruit and vegetable intake adequacy affect progression through the stages of
behavior change after nutritional intervention?” - should be explored in the
4. Discussion literature. Additional studies, including randomized controlled trials,
will be able to further describe the consequences of this type of mis-
This study identified a high prevalence of pseudomaintenance for perception on eating behavior for FV intake (Shepherd, 2002; Shepperd
FV intake at baseline. Baseline pseudomaintenance was associated with et al., 2013, 2015, 2017) and continue to answer our research question.
higher odds of progressing to higher stages of behavior change for fruit There is also a need to conduct additional robust randomized controlled
intake at follow-up. We found no association between baseline pseu- trials in order to understand how the baseline perception of intake af-
domaintenance and stage progression for vegetable intake. fects not only the stages of change but also FV intake.
As far as we know, this is the first report of intervention results The individuals in PM at baseline in this study may have shown
according to baseline pseudomaintenance for fruit and vegetable intake similar or higher stage progression as compared to those with a

6
M.C.R.d. Carvalho, et al.
Fig. 3. Effect of pseudomaintenance on the progression through stages of behavior change for fruit and vegetable intake according to logistic regression. Belo
Horizonte, Brazil, 2013–2014.
concordant perception. Nonetheless, given that the prevalence of “no
progression” was close to 50% in some subgroups, we believe the ap-
proach might still have prevented some of them from reflecting further
upon their FV intake and progressing to a higher stage of change.
Therefore, we propose some strategies for approaching FV intake in
future studies of nutritional intervention - strategies that can potentially
improve participants' results. First, all TTM-based intervention partici-
pants could benefit from a clear explanation of their stages of behavior
change, as we did in this intervention. We suggest adding personal
feedback about participants’ FV intake and the agreement between
perception and intake during the educational strategies (Miles & Scaife,
2003; Shepperd et al., 2013). This approach has the potential to pro-
mote reflection, problematization, and group discussion, which can
enhance empowerment and autonomy for all participants (Brasil, 2012;
Freire, 2013) regardless of the concordance or discordance between
their perception and intake. As a result, we expect these future trials to
show higher prevalences of stage progression at follow-up as compared
to our results, for both fruit and vegetables and regardless of the initial
concordance between intake and perception.
Additionally, given that accurate perception, estimation of intake,
and stage progression seem to be more complicated issues for vegetable
intake than for fruit intake (Carvalho et al., 2018; Dijkstra et al., 2014;
M. S. Lopes et al., 2017), we recommend that this food group be em-
phasized in the intervention. Furthermore, when discussing the risks of
not eating enough FV and how to avoid these risks, participants should
be stimulated to engage in realistic reflections about themselves instead
of talking about stereotypical images of “at-risk” people (Miles & Scaife,
2003). If they receive assistance in reflecting on their eating behavior
and FV intake in a more objective manner, they might be able to dis-
cover their motivations to pursue healthy changes and, therefore, pro-
gress to higher stages of behavior change (Ferrer & Klein, 2015; Miles &
Scaife, 2003; Shepperd et al., 2017).
Finally, the TTM does not specify which processes of change are
useful for individuals in PM. This gap must be explored. We suggest the
7
Appetite 151 (2020) 104682
use of specific processes of change among these individuals to approach
misperceived eating behavior and meet their particular needs (Kristal
et al., 1999; J. O.; Prochaska, Diclemente, & Norcross, 1992; J. O.;
Prochaska & Velicer, 1997). We believe that cognitive processes like
consciousness raising, dramatic relief, environmental reevaluation, and
self-reevaluation could be useful.
The strengths of this study include its large sample size, robust
design, and innovative methodology. However, we cannot disregard the
possibility of residual confounding. Another limitation is related to the
processes of change, which can be associated with stage progression
and could have increased the explanatory power of the regression
models but were not measured in this trial. However, processes of
change are not often measured in TTM trials; instead, they are em-
ployed during intervention, to facilitate stage progression (J O
Prochaska et al., 2013). Additionally, blinding of the research team and
intervention participants was not possible, as both the team and the
participants knew whether or not they were involved in the FV inter-
vention.
5. Conclusions
Individuals in pseudomaintenance for FV intake at baseline have
shown different patterns of stage progression for fruit intake and ve-
getable intake after the usual grouping for TTM-based intervention.
Being in PM for fruit at baseline was associated with higher odds of
stage progression at follow-up. No significant association was found
between being in PM for vegetables at baseline and stage progression at
follow-up.
We reinforce the need for additional research regarding the specific
stage progression for individuals in the PM stage of change, the changes
in FV intake among these individuals, and the adequate processes of
change for them, to further understand how to empower them to im-
prove eating behavior and make healthier food choices.
M.C.R.d. Carvalho, et al.
Funding
This work was supported by Minas Gerais State Research Support
Foundation (Fundação de Amparo à Pesquisa do Estado de Minas
Gerais, FAPEMIG) [grant numbers APQ-033376-12, 21618/2013, PPM-
00254-15, and a graduate studies scholarship for MCRC] and National
Council of Scientific and Technological Development (Conselho
Nacional de Desenvolvimento Científico e Tecnológico, CNPq) [grant
number 476686/2013–0, and a research productivity scholarship for
ACSL]. The funders had no role in the study design, collection, analysis
and interpretation of data, or writing and submission of this article.
Declaration of competing interest
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.appet.2020.104682.
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