Putting Prevention into Practice: An Evidence-Based Approach

Behavioral Counseling in Primary Care to Promote a Healthy Diet



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Am Fam Physician. 2003 Jul 1;68(1):147-148.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available at ww.ahrq.gov/clinic/serfiles.htm".

Case Study

More than 80 percent of Americans eat fewer than the recommended number of daily servings of fruit, vegetables, and grain products. Furthermore, they receive more than the recommended proportions of daily calories from saturated fat and total fat. You contemplate incorporating healthy diet counseling into the preventive care protocol for your practice. As a first step, you need to know if such counseling is effective, who would benefit most from the counseling, and which counseling tools would be most effective.

Case Study Questions

1. Which one of the following statements regarding the U.S. Preventive Services Task Force (USPSTF) recommendations on routine behavioral counseling to promote a healthy diet in unselected primary care patients is correct?

  • A. The USPSTF recommends routine behavioral counseling to promote a healthy diet only among adults in primary care settings.

  • B. The USPSTF recommends routine behavioral counseling to promote a healthy diet among adults, adolescents, and children in primary care settings.

  • C. The USPSTF recommends routine behavioral counseling to promote a healthy diet only among children in primary care settings.

  • D. The USPSTF found insufficient evidence to recommend for or against routine behavioral counseling to promote a healthy diet in primary care settings.

  • E. The USPSTF recommends against routine behavioral counseling to promote a healthy diet among adults, adolescents, and children in primary care settings.

2. The USPSTF recommends intensive behavioral dietary counseling for selected adult patients with which of the following conditions?

  • A. Obesity.

  • B. Hypertension.

  • C. Hyperlipidemia.

  • D. Hepatitis C.

3. Which one of the following statements regarding the USPSTF's findings about behavioral counseling to promote a healthy diet is correct?

  • A. Office-level system supports (e.g., prompts, reminders, counseling algorithms) do not significantly improve the delivery of appropriate dietary counseling by primary care clinicians.

  • B. Effective interventions combine nutrition education and weight-loss techniques.

  • C. No dietary assessment questionnaires have been validated for use in the primary care setting.

  • D. A promising counseling approach is medium-intensity, face-to-face dietary counseling in a few group or individual sessions.

  • E. Dietary counseling for children or adolescents in primary care settings has been found to be effective.

Answers

1. The correct answer is D. The USPSTF concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings. The USPSTF found fair evidence that brief, low- to moderate-intensity behavioral counseling in the primary care setting can produce small to medium changes in average daily intake of core components of a healthy diet. However, the outcome measures used, the duration of follow-up, and the types of study participants limit the strength of this evidence.

2. The correct answers are A, B, and C. The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. The largest effect of dietary counseling in asymptomatic adults has been observed with more intensive counseling (multiple sessions lasting 30 minutes or longer) among patients with hyperlipidemia, hypertension, or increased risk for diet-related chronic disease. Effective interventions include multisession individual or group sessions that combine nutrition education with behavioral counseling. The magnitude and duration of resulting changes are greater with higher-intensity interventions. These interventions often result in improvements in serum lipid levels, blood pressure, weight, or body mass index.

3. The correct answer is D. Two approaches appear promising for the general population of adult patients in primary care settings: (1) medium-intensity, face-to-face dietary counseling (two or three group or individual sessions) delivered by a dietitian, nutritionist, or specially trained primary care physician or nurse practitioner, and (2) lower intensity interventions that involve five minutes or less of primary care provider counseling supplemented by patient self-help materials, telephone counseling, or other interactive health communication. Effective interventions help patients acquire the skills, motivation, and support needed to alter their daily eating patterns and food preparation practices. Examples of behavioral counseling interventions include training in self-monitoring, overcoming barriers to selecting a healthy diet, goal setting, guidance with shopping and food preparation, role playing, and arranging for intra-treatment social support. Office level system support significantly improved primary care provider adherence to comprehensive dietary counseling. Although brief dietary assessment questionnaires have been validated for use in the primary care setting, their use may be limited by any bias of the respondent. Community-based studies have evaluated measures to reduce dietary fat intake in children, but no controlled trials of routine behavioral dietary counseling for children or adolescents in the primary care setting were identified.

SOURCES

Ammerman A, Pignone M, Fernandez L, Lohr K, Jacobs AD, Nester C, et al. Counseling to promote a healthy diet. Systematic Evidence Review No. 18 (Prepared by the RTI-University of North Carolina Evidence-based Practice Center under Contract No. 290-97-011). Rockville, Md.: Agency for Healthcare Research and Quality, 2002. Retrieved June 2003 at: www.ahrq.gov/clinic/serfiles.htm.

Pignone MP, Ammerman A, Fernandez L, Orleans CT, Pender N, Woolf S, et al. Counseling to promote a healthy diet in adults. A summary of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med. 2003;24:75–92.

U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet. Recommendations and rationale. Am J Prev Med. 2003;24:93–100.

The case study and answers to the following questions about behavioral counseling in primary care to promote a healthy diet are based on the recommendations of the current U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2002 and is an update of the 1996 recommendation on behavioral counseling to promote a healthy diet. More detailed information on this subject is available in the Systematic Evidence Review, Summary of the Evidence, and USPSTF Recommendations and Rationale on the AHRQ Web site (www.ahrq.gov). The Summary of the Evidence and the USPSTF recommendation and rationale statement are available in print through the AHRQ Publications Clearinghouse (800-358-9295).

This case study is part of AFP's CME. See “Clinical Quiz” on page 33.


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