Behavioral Counseling in Primary Care to Promote a Healthy Diet

Behavioral Counseling in Primary Care
to Promote a Healthy Diet
Recommendations and Rationale
U.S. Preventive Services Task Force
an overall healthy diet (especially saturated fat and
This statement summarizes the U.S. Preventive
fruit and vegetables) in unselected patients (see
Services Task Force (USPSTF) recommendations
“Scientific Evidence” for discussion of patient
on counseling to promote a healthy diet in
populations and intensity of interventions). The
primary care patients and the supporting
strength of this evidence, however, is limited by
evidence, and it updates the 1996
reliance on self-reported diet outcomes, limited use
recommendations contained in the Guide to
of measures corroborating reported changes in diet,
Clinical Preventive Services, second edition.1
limited follow-up data beyond 6 to 12 months, and
Explanations of the ratings and of the strength
enrollment of study participants who may not be
of overall evidence are given in Appendix A
fully representative of primary care patients. In
and Appendix B, respectively. The complete
addition, there is limited evidence to assess possible
information on which this statement is based,
harms (see “Clinical Considerations”). As a result,
including evidence tables and references, is
the USPSTF concluded that there is insufficient
available in the Systematic Evidence Review2
evidence to determine the significance and magnitude
on this topic, which can be obtained through
of the benefit of routine counseling to promote a
the USPSTF web site (www.preventiveservices
healthy diet in adults. Although community-based
.ahrq.gov) and through the National Guideline
studies have evaluated measures to reduce dietary fat
Clearinghouse™ (http:www.guideline.gov).
intake in children, no controlled trials of routine
The summary of the evidence and this
behavioral dietary counseling for children or
recommendation statement are also available
adolescents in the primary care setting were
in print through the AHRQ Publications
identified.
Clearinghouse (call 1-800-358-9295 or e-mail
ahrqpubs@ahrq.gov).
The USPSTF recommends intensive behavioral
dietary counseling for adult patients with
This was first published in Am J Prev Med.
hyperlipidemia and other known risk factors for
2003; 24(1):93-100.
cardiovascular and diet-related chronic disease.
Intensive counseling can be delivered by primary
Summary of
care clinicians or by referral to other specialists,
Recommendations
such as nutritionists or dietitians.
B recommendation.
The U.S. Preventive Services Task Force
(USPSTF) concludes that the evidence is
The USPSTF found good evidence that medium-
insufficient to recommend for or against routine
to high-intensity counseling interventions can produce
behavioral counseling to promote a healthy diet
medium to large changes in average daily intake of
in unselected patients in primary care settings.
I recommendation.
Corresponding Author: Alfred O. Berg, MD, MPH, Chair,
The USPSTF found fair evidence that brief, low-
U.S. Preventive Services Task Force, c/o David Atkins, MD,
MPH, Chief Medical Officer, Center for Practice and Technology
to medium-intensity behavioral dietary counseling in
Assessment, Agency for Healthcare Research and Quality,
the primary care setting can produce small to medium
6010 Executive Boulevard, Suite 300, Rockville, MD 20852.
changes in average daily intake of core components of
(301) 594-4016, fax (301) 594-4027, E-mail: uspstf@ahrq.gov.
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Behavioral Counseling in Primary Care to Promote a Healthy Diet
core components of a healthy diet (including
barriers, and Arrange regular follow-up and
saturated fat, fiber, fruit, and vegetables) among
support or refer to more intensive behavioral
adult patients at increased risk for diet-related
nutritional counseling (eg, medical nutrition
chronic disease. Intensive counseling interventions
therapy) if needed.
that have been examined in controlled trials among
• Two approaches appear promising for the general
at-risk adult patients have combined nutrition
population of adult patients in primary care
education with behavioral dietary counseling
settings: (1) medium-intensity face-to-face dietary
provided by a nutritionist, dietitian, or specially
counseling (2 to 3 group or individual sessions)
trained primary care clinician (eg, physician, nurse,
delivered by a dietitian or nutritionist or by a
or nurse practitioner). The USPSTF concluded that
such counseling is likely to improve important health
specially trained primary care physician or nurse
outcomes and that benefits outweigh potential harms.
practitioner, and (2) lower-intensity interventions
No controlled trials of intensive counseling in
that involve 5 minutes or less of primary care
children or adolescents that measured diet were
provider counseling supplemented by patient
identified.3,4
self-help materials, telephone counseling, or
other interactive health communications.
However, more research is needed to assess the
Clinical Considerations
long-term efficacy of these treatments and the
• Several brief dietary assessment questionnaires
balance of benefits and harms.
have been validated for use in the primary care
• The largest effect of dietary counseling in
setting.5,6 These instruments can identify dietary
asymptomatic adults has been observed with
counseling needs, guide interventions, and
more intensive interventions (multiple sessions
monitor changes in patients’ dietary patterns.
lasting 30 minutes or longer) among patients
However, these instruments are susceptible to the
with hyperlipidemia or hypertension, and among
bias of the respondent. Therefore, when used to
others at increased risk for diet-related chronic
evaluate the efficacy of counseling, efforts to verify
disease. Effective interventions include individual
self-reported information are recommended since
or group counseling delivered by nutritionists,
patients receiving dietary interventions may be
dietitians, or specially trained primary care
more likely to report positive changes in dietary
practitioners or health educators in the primary
behavior than control patients.7-10
care setting or in other clinical settings by
• Effective interventions combine nutrition
referral. Most studies of these interventions
education with behaviorally-oriented counseling
have enrolled selected patients, many of whom
to help patients acquire the skills, motivation,
had known diet-related risk factors such as
and support needed to alter their daily eating
hyperlipidemia or hypertension. Similar
patterns and food preparation practices.
approaches may be effective with unselected
Examples of behaviorally-oriented counseling
adult patients, but adherence to dietary advice
interventions include teaching self-monitoring,
may be lower, and health benefits smaller,
training to overcome common barriers to
than in patients who have been told they are
selecting a healthy diet, helping patients to set
at higher risk for diet-related chronic disease.12
their own goals, providing guidance in shopping
• Office-level systems supports (prompts, reminders,
and food preparation, role playing, and arranging
and counseling algorithms) have been found to
for intra-treatment social support. In general,
significantly improve the delivery of appropriate
these interventions can be described with
dietary counseling by primary care clinicians.13-15
reference to the 5-A behavioral counseling
framework11: Assess dietary practices and related
• Possible harms of dietary counseling have not
risk factors, Advise to change dietary practices,
been well defined or measured. Some have raised
Agree on individual diet change goals, Assist to
concerns that if patients focus only on reducing
change dietary practices or address motivational
total fat intake without attention to reducing
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Behavioral Counseling in Primary Care to Promote a Healthy Diet
caloric intake, an increase in carbohydrate intake
Despite well-established benefits of consuming a
(eg, reduced-fat or low-fat food products) may
healthy diet, more than 80% of Americans of all
lead to weight gain, elevated triglyceride levels,
ages eat fewer than the recommended number of
or insulin resistance. Nationally, obesity rates
daily servings of fruit, vegetables, and grain products
have increased despite declining fat consumption,
and more than the recommended proportions of
but studies did not consistently examine effects
daily calories from saturated fat and total fat.17 In
of counseling on outcomes such as caloric intake
1994-1996, 28% of people aged 2 years and older
and weight.
consumed at least 2 daily servings of fruit, 49%
consumed at least 3 daily servings of vegetables,
• Little is known about effective dietary counseling
51% consumed at least 6 daily servings of grain
for children or adolescents in the primary care
products, 36% consumed less than 10% of daily
setting. Most studies of nutritional interventions
calories from saturated fat, and 33% consumed
for children and adolescents have focused on
30% or less of daily calories from total fat.17
non-clinical settings (such as schools) or have
used physiologic outcomes such as cholesterol
Dietary counseling practices of primary care
or weight rather than more comprehensive
clinicians indicate limited attention to diet
measures of a healthy diet.3,4
modification. In a 1999-2000 survey of U.S.
adults, 33% of respondents reported past-year
Scientific Evidence
physician advice to eat more fruits and vegetables,
and 29% reported similar advice to reduce dietary
fat.18 In another recent survey, 25% of adult
Epidemiology and
patients from four community-based group family
Clinical Consequences
medicine clinics indicated that their physicians had
Consuming a healthy diet is associated with
advised them to limit or reduce the amount of fat
lower risks for chronic disease morbidity and
in their diets.19
mortality. Four of the 10 leading causes of death—
coronary heart disease, some types of cancer, stroke,
Effectiveness of
and type 2 diabetes—are associated with unhealthy
Dietary Counseling
diets.2 The relationships between dietary patterns
and health outcomes have been examined in a
The ideal evidence to support behavioral dietary
wide range of observational studies and randomized
counseling would link counseling directly to
trials with patients at risk for diet-related chronic
improved health outcomes in randomized controlled
disease. The majority of studies show that people
clinical trials. In the absence of such evidence, the
consuming diets that are low in fat, saturated fat,
clinical logic behind counseling is based on a chain
trans-fatty acids, and cholesterol and high in fruits,
of critical assumptions: (1) the clinician must be
vegetables, and whole grain products containing
able to assess whether a patient is consuming a
fiber have lower rates of morbidity and mortality
healthy diet, (2) critical components of counseling
from coronary heart disease, and possibly several
must be routinely replicable, (3) counseling must
forms of cancer. In addition, one needs to balance
lead to sustained improvements in diet, and (4) the
calories with physical activity to maintain a healthy
health benefits of these changes in diet must be
weight. The Dietary Guidelines for Americans16
established and known to exceed the potential
recommend 3 to 5 daily servings of vegetables and
harms of intervention.11 A review conducted for
vegetable juices, 2 to 4 daily servings of fruits and
the USPSTF identified 21 fair to good quality
fruit juices, and 6 to 11 daily servings of grain
randomized controlled clinical trials of dietary
products, depending on caloric needs. In addition,
counseling among patients without existing diet-
they recommend a diet that contains less than 10%
related chronic disease (eg, coronary heart disease
of calories from saturated fat, no more than 30% of
or cancer). Trials had to include follow-up of at least
calories from total fat, and limited consumption of
3 months after intervention for at least 50% of the
trans-fatty acids.
enrolled subjects and include measures of dietary
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Behavioral Counseling in Primary Care to Promote a Healthy Diet
intake. Studies that assessed only physiologic
Assessing Dietary Behaviors
measures (eg, lipid levels, weight, or body mass
in Primary Care Patients
index [BMI]) were not included. Additional details
A number of brief, validated dietary assessment
of the inclusion and exclusion criteria, and methods
instruments can identify dietary counseling needs,
for assessing quality of studies, are described
guide intervention, and monitor change among
elsewhere.2,20
adult patients in primary care and other clinical
Most of these trials focused exclusively on dietary
settings. Most of these instruments can be self-
counseling, though some targeted diet as part of a
administered, are easily scored, have fewer than
broader risk-factor modification program that also
40 items, and take 10 minutes or less to administer.
addressed smoking and sedentary lifestyle.21-24 Most
However, these instruments are susceptible to bias
studies targeted reductions in total fat or saturated
(ie, patients report healthier diets than they actually
fat intake (n=17).7-9,13-15,21-33 Ten studies targeted
consume); some studies indicate that under-
increased fruit and vegetable intake8,9,12,21,25-27,32,34,35
reporting of caloric intake is common, especially
and 7 targeted increased intake of fiber and whole
among obese patients.10 When used to evaluate
grains.7,13,22,26,27,32,36 Most studies (n=11) focused on a
counseling efficacy, efforts to verify self-reported
single nutrient, although 10 focused on changes in
information are recommended.7-10,13,24,42 For children
2 or more nutrients.7-9,13,21,22,25-27,32
aged 9 years and older, food frequency questionnaires
administered directly to children can provide a
Studies were classified by intensity of the
reasonably accurate picture of usual dietary patterns,
interventions evaluated, based on the number and
with correlations with criterion measures ranging
length of counseling sessions, the magnitude and
from 0.46 to 0.79.6 No brief valid dietary screening
intensity of educational materials provided, and the
instruments were identified for children below the
use of supplemental interventions such as support
age of 9 years. The optimal interval for screening
group sessions or cooking classes. Low-intensity
adults or children is not known.
interventions involved 1 contact lasting less than
30 minutes. High-intensity interventions involved
Effectiveness of Routine
more than 6 contacts lasting more than 30 minutes.
Counseling in Primary Care
Medium-intensity interventions fell between low-
The USPSTF found 9 fair to good quality
and high-intensity.
randomized controlled trials of behavioral dietary
Effects of counseling were classified as “large,”
counseling in unselected populations in primary
“medium,” or “small” for each component of diet
care settings. The majority of these interventions
measured.2 With reference to these specific, defined
focused on change in more than one nutrient
categories, the USPSTF concluded that large effects
(ie, fat/saturated fat, fruit/vegetables, and/or
sustained over time were likely to produce important
fiber).7,9,13,25-27,32 Most of these trials combined basic
health benefits (reductions in morbidity and
nutrition education with behaviorally-oriented
mortality).37-41 Given the large attributable risk
counseling to help patients acquire the skills,
associated with these dietary components, it is
motivation, or support needed to alter their daily
possible that medium or even small changes in diet
eating patterns and food selection and preparation
would yield important health benefits across a large
practices. Duration of interventions lasted from
population. However, to date, there is little direct
1 week to 1 year. No controlled trials with children
evidence about the effect of small and medium
or adolescents were identified.
dietary changes on the future risk for coronary
The 9 studies varied in the amount of face-to-face
heart disease, making it difficult to determine with
counseling involved. Two studies of medium-intensity
certainty whether such changes will translate into
interventions evaluated multiple face-to-face sessions
changes in the incidence of chronic disease. Better
of behavioral dietary counseling provided in the
data about these linkages are needed.
primary care setting by a dietitian or nutritionist,
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Behavioral Counseling in Primary Care to Promote a Healthy Diet
or by a primary care physician or nurse practitioner
counseling sessions. One intervention extended
who had received brief training in dietary
over a 6-month period and aimed at increasing
counseling.32,36 These interventions involved 2 to
fruit and vegetable intake12; the other extended
3 group or individual sessions lasting 30 minutes,
over a 5-year period and focused on dietary fat
with follow-up visits at 1 and 3 months. Baron
reduction. Both trials reported large treatment
et al reported an 84% patient recruitment/
effects in self-reported dietary behavior at 6-month
participation rate.36
post-intervention follow-up, and both reported
favorable changes in biological risk factors or
Seven studies involved little or no face-to-face
markers. However, participants in these studies
counseling and placed greater emphasis on patient
were highly selected and motivated volunteers. The
self-help materials, manuals, and varied forms of
USPSTF concluded that results could not be
interactive health communication. Two were studies
generalized to more representative primary care
of low-intensity interventions that combined brief
populations.
(<5 minutes) face-to-face counseling sessions with
a primary care physician or nurse with self-help
Effectiveness of Intensive
materials.7,13 Three others were studies of low-
intensity interventions that relied either on mailed
Counseling in Patients
self-help materials25,34 or on health behavior change
at Risk for Chronic Disease
messages delivered via an automated computer-based
The USPSTF found 10 fair to good quality
voice system.27 Campbell et al25 found significantly
randomized controlled trials that tested whether
greater benefits from tailored than non-tailored self-
medium- to high-intensity interventions delivered
help materials; Lutz et al34 did not. The remaining 2
in primary care or other clinical settings led to
were medium-intensity interventions that combined
improved dietary outcomes among adults who were
a computer-generated personalized letter and
identified as being at increased risk for diet-related
motivational phone call(s) from a trained health
chronic disease.8,14,15,21-24,28-31,35 For 2 of these trials,
educator with a series of self-help mailings and
2 research reports for each were reviewed.14,15,28,29 No
newsletters.9,26 Patient recruitment and participation
controlled trials with children or adolescents at risk
in this second group of studies ranged from 16%34
for chronic disease were identified that reported
to 80%,25 with most in the 40% to 70% range.
dietary outcomes.
These studies in unselected populations
The interventions involved a two-step assessment:
produced mostly small (n=9) and medium (n=8)
screening to identify a patient’s risk status using
as opposed to large (n=3) improvements in self-
chart audit/clinical exam/laboratory testing to
reported dietary behaviors, most of which were
screen for hyperlipidemia, hypertension, family
statistically significant. Most studies followed
history of heart disease or breast cancer, overweight,
patients for 6 months or less post-intervention; 4
obesity, smoking status, and sedentary lifestyle,
followed patients for as long as 12 months.9,13,32,36
followed by assessment of dietary practices using a
Only 2 of them assessed impacts on intermediate
variety of dietary assessment tools and protocols
biological endpoints (eg, serum cholesterol, weight,
(eg, food frequency questionnaires, 3-4 day food
or BMI), of which none reported significant
records, and brief dietary assessment instruments).
treatment effects.13,36 No studies examined adverse
Hyperlipidemia was included as a risk factor in
treatment effects.
most of these studies. Four trials addressed diet
along with physical activity and/or smoking.21-24
The USPSTF also reviewed 2 additional
studies that enrolled predominantly healthy
Most of the trials tested multi-session group
premenopausal women, a large proportion of
or individual counseling that combined nutrition
whom were overweight or obese. These studies
education with behaviorally-oriented counseling.
employed high-intensity interventions involving
Most studies focused on reducing saturated fat
multiple dietitian-led individual12 or group33
and/or total fat intake; 2 of these studies also
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Behavioral Counseling in Primary Care to Promote a Healthy Diet
targeted fiber or fruit and vegetable intake,21,22 and
Discussion
one focused on increasing fruit and vegetable intake
Medium- to high-intensity behavioral
only.35 Most studies also reported intermediate
interventions appear to produce consistent,
health outcomes, such as serum lipid levels, blood
sustained, and clinically important changes in dietary
pressure, weight, and/or BMI. Follow-up in most
intake of total fat, saturated fat, fruit and vegetables,
studies (n=6) was 12 months or longer, some as
and fiber. However, these trials were generally either
long as 4 to 6 years.21-24,28-30
conducted with patients with known risk factors for
diet-related chronic disease, or performed in special
Six of the trials took place outside of primary
clinics with highly selected patients and specially
care settings, where counseling was provided by an
trained providers. The most effective interventions
experienced nutritionist, dietitian, and/or health
generally combined education, behaviorally-oriented
educator in 8 to 20 sessions over a period ranging
counseling, and patient reinforcement and follow-up.
from 4 months to 5 to 6 years.8,21,23,28,29,31,35 Four trials
More intensive interventions, and those of longer
took place within primary care settings,14,15,22,24,30
duration, are associated with larger magnitude of
where counseling was provided by specially trained
benefit and more sustained changes in diet. Available
primary care physicians or nurses (training ranging
studies do not, however, allow firm conclusions
about the essential or most effective elements of
from 60 minutes to 3 days) in 3 to 6 special sessions
these multi-component interventions, their relative
supplemented by follow-up phone calls and/or
effect on specific dietary constituents (eg, fat, fruit
newsletters, and follow-up at routine visits over a
and vegetables, or fiber), or the relative efficacy of
period of 4 to 18 months. In two primary care-
targeting single or multiple dietary risks or
based studies,14,15,30 behavioral dietary counseling for
addressing diet in the context of broader lifestyle
patients with hyperlipidemia was supplemented, if
interventions. Although evidence is stronger for
needed, with lipid-lowering medication and/or
counseling patients who are at increased risk for
referral to outside counseling by a dietitian. Ockene
chronic disease, such as those with hyperlipidemia,
et al15 found that implementing office-level systems
than for the general population of patients, it is not
supports (prompts, reminders, and counseling
possible to disentangle the effects of patient risk
status from the effects of intervention intensity.
algorithms) significantly improved primary care
Adherence to these intensive interventions and the
provider adherence to the comprehensive dietary
dietary changes they require may be dependent on
counseling.
patients’ heightened perceived risk and motivation
In summary, interventions for patients at risk for
for change.
chronic disease resulted in dietary behavior changes
Existing trials of routine dietary interventions in
that were small (n=3),14,15,21,22 medium (n=6),8,21,22,24,30,35
unselected primary care populations have generally
and large (n=4),8,23,28,31 most of which were statistically
produced only small to medium changes in self-
significant. The magnitude and duration of these
reported diet. Although direct comparisons cannot
changes were greater with higher intensity
be made, results from medium-intensity, routine
interventions than with interventions of lower
face-to-face counseling from nutritionists, dietitians,
or specially trained primary care practitioners
intensity. More than one-half of these studies found
(physicians, nurses, or nurse practitioners) appear
that self-reported dietary changes were accompanied
similar to those achieved through less intensive,
by significant improvements in serum lipids, weight,
minimal-contact interventions to supplement brief
or BMI.8,21,22,28-30 These findings help corroborate
primary care provider advice/counseling. The
patients’ self-reported dietary changes and confirm
consistently positive effects of such interventions on
the overall health benefits of the observed changes
diet in unselected patient populations establish these
in diet.
interventions as highly promising as part of routine
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Behavioral Counseling in Primary Care to Promote a Healthy Diet
preventive care for patients at average risk for chronic
to all patients, based on a limited number of trials
disease. The USPSTF concluded, however, that
of counseling.49
existing studies do not provide sufficient evidence
Recommendations on nutritional counseling for
to recommend these interventions for widespread
patients at risk (eg, those who have hypertension or
use due to a number of limitations such as modest
hyperlipidemia) have been issued by the American
overall patient recruitment/participation rates,
Dietetic Association (ADA) and two panels
reliance on self-reported outcome measures, relatively
sponsored by the National Institutes of Health
short follow-up periods, uncertainty about the
(NIH) National Heart, Lung, and Blood Institute.
health effects of small and medium changes in diet,
The ADA recommends that primary care providers
and the lack of evidence about possible adverse
screen for nutrition-related illnesses, prescribe diets,
effects of counseling. Two studies suggest high-
provide preliminary counseling on specific nutritional
intensity interventions can be effective in selected
needs, follow up with patients, and refer patients to
patients at average risk, but the applicability of
appropriate dietetic professionals when necessary.50
these findings and the feasibility of these
Similarly, The Joint National Committee on
interventions in primary care settings are
Prevention, Detection, Evaluation, and Treatment
uncertain.12,33
of High Blood Pressure recommends that dietary
assessments be included as part of routine medical
history and that physicians counsel patients on
Recommendations of Others
lifestyle modifications for the prevention and
Dietary guidelines for the general population
treatment of high blood pressure (lose weight if
have been issued by the U.S. Department of
overweight, limit alcohol intake, reduce sodium
Agriculture (USDA)16 and the Department of
intake, reduce saturated fat and cholesterol intake).51
Health and Human Services; specific dietary
The National Cholesterol Education Program
objectives for the nation are outlined in Healthy
recommends that individuals with elevated levels
People 2010.17 Guidelines from the American Heart
of low density lipoprotein limit their intake of fats,
Association (AHA) and the American Cancer
particularly saturated fats, and cholesterol and
Society (ACS) address diets that will lower the risk
increase dietary fiber.52
for heart disease and cancer, respectively.43,44 These
guidelines generally agree in recommending a diet
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