Physician recommendations for dietary change: their prevalence and impact in a population-based sample

Primary care patients' and providers' perspectives about an online weight management program integrated with population health management: Post-intervention qualitative results from the PROPS study

Objective

To assess patients' and providers' attitudes about the online weight management program and population health management approach in the PROPS Study, which examined the effectiveness of these strategies in primary care.

Methods

We conducted semi-structured interviews with 22 patients and nine providers. Using thematic analysis, we analyzed transcripts of the interviews to identify key themes.

Results

Most patients found the online program to be well-structured and easy to use, although a few noted that the information was overwhelming or could be more personalized. Patients mentioned that the support from the population health managers was critical for their success, and several reported that they would have liked more involvement from their primary care provider or a dietitian. Providers also were satisfied with the interventions, and several stated that the population health management support was helpful because it added accountability. Providers suggested that the interventions could be improved by tailoring the information and integrating the online program with the electronic health record.

Conclusion

Most patients and providers were satisfied with the interventions, with several recommendations for improvements.

Innovation

These findings give additional information about patients' and providers' experience with this innovative approach for managing overweight and obesity in primary care.

Primary Care Patients' and Providers' Perspectives about an Online Weight Management Program: a Qualitative Study

BACKGROUND

Primary care providers (PCPs) often take the lead role in caring for patients with overweight and obesity; however, few PCPs counsel patients about weight loss. Online weight management programs that are integrated within primary care may help address this gap in care.

OBJECTIVE

To identify perceptions of and experience with online weight management programs in general and with a proposed online program, to identify barriers to use, and to improve the design and content of our intervention, which included an online program plus population health management (PHM) support from primary care practices.

DESIGN

A mixed qualitative methods study including three patient focus groups and seven semi-structured interviews with healthcare providers.

PARTICIPANTS

A total of 13 adult patients (age range, 20-70) with body mass index (BMI) 27-35 kg/m² attended the focus groups. In-person semi-structured interviews were conducted with seven healthcare providers (three PCPs, two population health managers, one primary care nurse, and one registered dietitian).

MAIN MEASURES

We developed and used semi-structured focus groups and interview guides. The focus group and interviews were recorded and transcribed. Using grounded theory, we analyzed the transcripts to identify and extract common concepts and themes.

KEY RESULTS

Although patients and healthcare providers expressed positive opinions about online weight management programs, few patients had experience with them, and providers stated that such programs are not being widely implemented in primary care settings. Some participants highlighted the flexibility and low cost as strengths of online weight management tools compared with in-person programs. All participants had favorable opinions about our proposed intervention and were overwhelmingly positive about the combination of an online program and PHM support.

CONCLUSIONS

This study highlights the potential value of online weight management programs and PHM support in primary care.

CLINICAL TRIALS REGISTRATION

NCT02656693.

The impact of health information technology on cancer care across the continuum: a systematic review and meta-analysis

INTRODUCTION

Health information technology (HIT) has the potential to play a significant role in the management of cancer. The purpose of this review is to identify and examine empirical studies that investigate the impact of HIT in cancer care on different levels of the care continuum.

METHODS

Electronic searches were performed in four academic databases. The authors used a three-step search process to identify 122 studies that met specific inclusion criteria. Next, a coding sheet was used to extract information from each included article to use in an analysis. Logistic regression was used to determine study-specific characteristics that were associated with positive findings.

RESULTS

Overall, 72.4% of published analyses reported a beneficial effect of HIT. Multivariate analysis found that the impact of HIT differs across the cancer continuum with studies targeting diagnosis and treatment being, respectively, 77 (P = .001) and 39 (P = .039) percentage points less likely to report a beneficial effect when compared to those targeting prevention. In addition, studies targeting HIT to patients were 31 percentage points less likely to find a beneficial effect than those targeting providers (P = .030). Lastly, studies assessing behavior change as an outcome were 41 percentage points less likely to find a beneficial effect (P = .006), while studies targeting decision making were 27 percentage points more likely to find a beneficial effect (P = .034).

CONCLUSION

Based on current evidence, HIT interventions seem to be more successful when targeting physicians, care in the prevention phase of the cancer continuum, and/or decision making. An agenda for future research is discussed.

The role of patient-clinician information engagement and information seeking from nonmedical channels in fruit and vegetable intake among cancer patients

Previous research suggests positive effects of health information seeking on prevention behaviors such as diet, exercise, and fruit and vegetable consumption. The present study builds upon this research and strengthens causal claims from it by examining the lagged effect of patient-clinician information engagement on fruit and vegetable consumption as well as the indirect effect on the outcome through seeking information from nonmedical channels. The results are based on data collected from a randomly drawn sample of breast, prostate, and colorectal cancer patients from the Pennsylvania Cancer Registry who completed mail surveys in the Fall of 2006 and 2007. There was a 65% response rate for baseline subjects (resulting n = 2,013); of those, 1,293 were interviewed 1 year later, and 1,257 were available for our analyses. Results show a positive lagged main effect of patient-clinician information engagement at baseline on fruit and vegetable consumption at follow-up (B = 0.26, SE = 0.10, p = .01). The mediation analysis shows that patient-clinician information engagement leads to increased fruit and vegetable consumption among cancer patients, in part through patients' information seeking from nonmedical channels. Implications of these findings for the cancer patient population and for physicians are discussed.

Capitalizing on the "teachable moment" to promote healthy dietary changes among cancer survivors: the perspectives of health care providers

PURPOSE

Although cancer is often thought of as a teachable moment, many cancer survivors do not adhere to behavioral recommendations that might improve their health. This study explored health care providers' perspectives on the importance and feasibility of addressing behavior change, specifically healthy diet, with cancer survivors.

METHODS

In-depth interviews were conducted with 33 health care providers who care for posttreatment survivors of breast cancer, prostate cancer, and non-Hodgkin's lymphoma. Interviews were analyzed thematically.

RESULTS

Health care providers emphasized the strength of evidence linking diet/obesity to recurrence in their assessment of the importance of promoting dietary change among their survivor patients. Cancer specialists (e.g., oncologists, surgeons) generally brought up dietary change with patients if they considered the evidence to be strong. In contrast, primary care providers viewed health promotion as important for all patients and reported treating cancer survivor patients the same as others when it came to making dietary recommendations. There was a lack of consensus among providers on the best timing to bring up behavior change. Providers described specific subgroups of patients who they saw as more motivated to make behavior changes and patient barriers to making dietary changes.

CONCLUSIONS

Health care providers can play an important role in promoting healthy diet among cancer survivors. As the evidence base around diet and cancer recurrence/prognosis grows, it is important that this information is communicated to providers. Strategies such as incorporating behavior change messages into survivor care plans may help standardize recommendations to survivors.

Insights from the POWER practice-based weight loss trial: a focus group study on the PCP's role in weight management

BACKGROUND

Despite U.S. Preventive Services Task Force recommendations, few primary care providers (PCPs) counsel obese patients about weight loss. The POWER practice-based weight loss trial used health coaches to provide weight loss counseling, but PCPs referred their patients and reviewed their patients' progress reports. This trial provided a unique opportunity to understand PCPs' actual and desired roles in a multi-component weight loss intervention.

OBJECTIVE

1) To explore the PCP role, inclusive of and beyond the trial's intended role, in a practice-based weight loss trial; and 2) to elicit recommendations by PCPs for wider dissemination of the successful multi-component program.

DESIGN

Qualitative focus group study of PCPs with ≥ 4 patients enrolled in trial.

PARTICIPANTS

Twenty-six out of 30 PCPs from six community practices participated between June and August 2010.

MAIN MEASURES

We used a semi-structured moderator guide. Focus groups were audio-recorded and transcribed verbatim. Two investigators independently coded transcripts for thematic content, identified meaningful segments within the responses and assigned codes using an editing style analysis. Atlas.ti software was used for organization/analysis.

MAIN RESULTS

We identified five major themes related to the PCP's role in patients' weight management: (1) refer patients into program, provide endorsement; (2) provide accountability for patients; (3) "cheerlead" for patients during visits; (4) have limited role in weight management; and (5) maintain the long-term trusting relationship through the ups and downs. PCPs provided several recommendations for wider dissemination of the program into primary care practices, highlighting the need for specific feedback from coaches as well as efficient, integrated processes.

CONCLUSIONS

Weight loss programs have the potential to partner with PCPs to build upon the patient-provider relationship to improve patient accountability and sustain behavior change. However, rather than directing the weight loss, PCPs preferred a peripheral role by utilizing health coaches.

Factors related to weight loss behavior in a multiracial/ethnic workforce

OBJECTIVES

We examined whether factors associated with attempting to lose weight in a hospital-based employee workforce varied by race/ethnicity.

METHODS

We conducted a cross-sectional survey in 6 hospitals in a health system in central Massachusetts. The stratified random sample included 813 employees; men and and non-White employees were oversampled. The primary outcome measure was current evidence-based weight loss attempts.

RESULTS

Factors positively associated with attempting to lose weight among non-Hispanic Blacks included self-perceived overweight, female sex, higher education, physician recommendation to lose weight, and having a chronic medical condition. Among Hispanics, body mass index and self-perceived overweight were associated with attempts to lose weight, while working full time and second or third shift were associated with lower likelihood of weight loss attempts. Among non-Hispanic Whites, self-perceived overweight, female sex, higher education, and physician recommendation to lose weight were positively associated with attempting to lose weight, while working full time and working third shift were negatively associated.

CONCLUSIONS

Rates of overweight and obesity were high among hospital employees. Findings suggest that factors associated with attempting to lose weight vary across racial and ethnic groups. Workplace-based interventions for weight control should include strategies tailored to these differences.

Randomized controlled trial: effect of nutritional counselling in general practice

OBJECTIVES

To investigate the effectiveness of a non-structured 15-min educational intervention by general practitioners (GPs) on modifications of daily diet among healthy adults.

DESIGN

Two arms randomized trial lasting 12 months.

SETTING

Italian general practitioner wards. Subjects A total of 3,186 men and women aged 18-65 years recruited in the medical ward by their GPs.

INTERVENTIONS

An educational intervention and a brochure on the basics of a healthy diet based on the Italian Guidelines for a Correct Nutrition, 1998. The main study goal was to attain an intake of fruits and vegetables >5 servings per day. Follow-up visit every 6 months. Main outcome measures Weight, blood pressure, and a 40-items Food Frequency Questionnaire.

RESULTS

The intervention group showed a slightly reduced net intake of meat and a slightly increased net intake of fruits and vegetables, fish products, and olive oil. Body mass index (BMI) changed only in the treatment arm [-0.41 95% confidence interval (95% CI) -0.11 to -0.53]. The net change at 1 year in the intervention arm was +1.31 (CI 0.90-4.39) for fruits and vegetables, and -0.22 (-0.11 to -0.69) for meat (portions per week). We also computed a 'healthy diet score' reflecting compliance with recommended dietary habits. In the intervention group, the mean score at recruitment was significantly lower than the mean score at the end of follow-up (Crude score change = 0.29; CI 0.19-0.48). No differences were observed in the control group (Crude score change = -0.04; CI -0.22-0.02). The difference in score from baseline to the final visit, comparing the intervention vs the control group, was statistically significant (P < 0.001) (MANOVA adjusted by sex, BMI, education, and time).

CONCLUSIONS

A brief educational intervention by GPs can induce multiple diet changes that may lower BMI and potentially reduce chronic disease risk in generally healthy adults.

The nutritional knowledge of Australian nurses

Sound nutrition is an essential component of good health. A number of health professionals, including nurses, provide nutritional information to the community. However, little research exists which measures the nutrition knowledge of nurses in Australia. The aim of this study was to determine the nutrition knowledge of nurses in regional Victoria. A descriptive cross-sectional study design was used with 103 nurses (81% currently practicing in an acute regional hospital). The nurses answered 48 multiple choice general knowledge questions (using a valid and reliable questionnaire) and provided educational and demographic details. Each multiple choice question was scored as correct or incorrect and given the value of one point (maximum possible 48 points). The mean knowledge score for all nurses was 60.2% (SD = 8.4). Older nurses, those with more years of experience, and nurses with general training (rather than a degree) scored higher average knowledge scores. Respondents reported requests for nutrition information from patients and clients, and indicated that the most frequently used nutrition information sources were dietitians, other nurses, professional journals, books and literature from the National Heart Foundation. The nutrition knowledge score reported in this study is low to moderate by definition from previous studies using the same questionnaire. It is recommended that the Australian nursing profession determines its own nutrition knowledge standard and the nutrition knowledge needs of nurses working in particular areas of practice. Further work is required to determine the validity and reliability of an Australian knowledge instrument.

Provision of health counseling in office-based practices and hospital outpatient clinics

OBJECTIVE

To compare the rates of health counseling provided during primary care visits in two different types of ambulatory care settings.

METHODS

Secondary analysis of the 2000 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).

RESULTS

Of the estimated 722 million adult ambulatory care visits during 2000, 90.8% were made to office-based physician practice settings and 9.2% to hospital-based outpatient departments. Consistent with previous reports, the demographic profile of patients who seek primary care in hospital outpatient departments differs from those seen in office-based practices. Provision of health counseling for exercise [OR = 1.4; 95% confidence intervals (CI): 1-1.8], diet (OR = 1.6; 95% CI: 1.2-2.3), breast self-exam (OR = 2; 95% CI: 1.1-3.6) and stress management (OR = 1.7; 95% CI: 1-2.7) during patient visits was more likely to be reported in the office-based practices than in hospital outpatient clinics. The visit-based rates of health counseling for HIV/STD prevention, tobacco use, mental health or injury prevention were low in both settings.

CONCLUSIONS

There is opportunity to improve rates of preventive counseling in primary care settings and to reduce disparities that exist. Identifying the reasons for these disparities and effective interventions will be important steps in providing equitable care in the area of preventive health counseling.

Randomized trial of a low-intensity dietary intervention in rural residents: the Rural Physician Cancer Prevention Project

BACKGROUND

Dietary behavior, specifically a low-fat, high-fiber diet, plays a role in the primary prevention of chronic diseases including cancer.

DESIGN

A community-based randomized trial to assess the impact of a low-intensity, physician-endorsed, self-help dietary intervention that provided tailored dietary feedback, and was designed to promote improved fat and fiber behavior in a rural, low-education/low-literacy, partly minority population. The data were collected from 1999 to 2003.

SETTING/PARTICIPANTS

A total of 754 patients from three physician practices in rural Virginia completed a baseline telephone survey assessing dietary and psychosocial information, and were then randomly assigned to the intervention or control condition. Follow-up telephone evaluation was based on 522 participants at 1 month, 470 at 6 months, and 516 participants at 12 months.

INTERVENTION

A series of tailored feedback, followed by brief telephone counseling and theory-based nutritional education booklets, provided by staggered delivery to the home.

MAIN OUTCOME MEASURES

Dietary fat and fiber behavior, dietary intentions to change, self-efficacy for dietary change, and fat and fiber knowledge.

RESULTS

The intervention group demonstrated significant improvement in dietary fat and fiber behaviors and intentions to change fat and fiber intake (p <0.05) at 1, 6, and 12 months.

CONCLUSIONS

The Rural Physician Cancer Prevention Project provides an effective model for achieving public health-level dietary health behavior changes among a rural, minority, and low-literacy/low-education population.

Do nurse practitioners make a difference in provision of health counseling in hospital outpatient departments?

PURPOSE

This study examined whether nurse practitioners (NPs) had any impact on the type and amount of health counseling provided during patient visits to hospital outpatient departments (OPDs).

DATA SOURCES

This is a secondary data analysis of the National Hospital Ambulatory Medical Care Survey from 1997 to 2000. Only patient visits to hospital OPDs were included. Rates of health counseling provided at patient visits involving an NP were compared with those without an NP. Adjusted odds ratio was reported separately for each type of health counseling provided at patient visits for nonillness care, for chronic problems, and for acute problems.

CONCLUSIONS

Health counseling for diet, exercise, human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention, tobacco use, and injury prevention are more likely to be provided at nonillness care visits involving an NP than at those not involving an NP. The presence of an NP is associated not only with higher rates of counseling for diet, exercise, and tobacco use provided at patient visits for chronic problems but also with higher rates of counseling for diet and HIV/STD prevention provided at patient visits for acute problems.

IMPLICATIONS FOR PRACTICE

This study indicates an important role NPs can play in providing preventive services in outpatient hospital departments. The findings reflect the emphasis of the NP education on health counseling and patient education in clinical practice.

Accuracy of recall of exercise counseling among primary care patients

BACKGROUND

In evaluating the efficacy of health care provider counseling to encourage patients to modify health behaviors such as physical activity, it is important to be able to accurately measure the extent of health care provider counseling.

METHODS

The Physical Activity Exit Interview (PAEI) is a brief measure of a patient's perception of the content of physical activity promotion counseling received during a visit with his or her physician. Forty-three primary care patients, and their physicians, completed a PAEI following a visit, which was compared to an audiotape of the visit that was coded to identify the physical activity counseling steps taken.

RESULTS

Participants were 67% female, 81.7% white, and had a mean age of 47.1 years. Overall, there was good concordance in the overall number of counseling activities reported between patients and audiotapes (r = 0.47, P < 0.01), patients and physicians (r = 0.51, P < 0.01), and between physicians and audiotapes (r = 0.57, P < 0.01). Significant differences between the three measurement methods (patient exit interview, physician exit interview, audiotape) existed for only 4 of 12 items.

CONCLUSIONS

The PAPEI was overall accurate in measuring the content of physical activity counseling, though accuracy differed between items. When discrepancy occurred, it was typically due to patient overreporting of counseling steps.

Implementation of a cancer prevention program for working class, multiethnic populations

BACKGROUND

This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations.

METHODS

Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials.

RESULTS

Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled.

CONCLUSIONS

Collection and reporting on process evaluation results can help explain variations in program implementation.

Physicians' weight loss counseling in two public hospital primary care clinics

PURPOSE

Primary care physicians are an important source of information on weight management. Nevertheless, weight loss counseling by these physicians remains inadequate. This study sought to determine physicians' barriers to providing weight loss counseling in a public hospital, patients' recall of physicians' weight loss recommendations, and the influence of physicians' counseling on patients' understanding, motivation, and behavior regarding weight loss.

METHOD

In 2001, four focus groups of faculty and residents were held at two primary care clinics affiliated with the Louisiana State University Health Sciences Center-Shreveport to determine the barriers to providing weight loss counseling. Scripted probes were used to uncover consensus norms. In 2001-02, structured exit interviews were conducted with 210 overweight or obese patients recruited from the clinics to determine patients' recall of physicians' weight loss recommendations, and patients' understanding of the relationship between weight and health, and their stages of readiness for weight loss.

RESULTS

Physicians identified major barriers to providing weight loss counseling, including insufficient confidence, knowledge, and skills. Obesity was underdocumented as a distinct clinical diagnosis. Only 5% of the patients recalled being given the combined weight loss strategy of diet and exercise. However, patients who recalled being counseled to lose weight were more likely to understand the risks of obesity, the benefits of weight loss, and were at a higher stage of readiness for weight loss.

CONCLUSIONS

Physicians' weight loss counseling had a significant effect on patients' understanding of and motivation for weight loss. However, physicians provided insufficient guidance on weight management strategies, possibly because of inadequate counseling skills and confidence.

REAP and WAVE: new tools to rapidly assess/discuss nutrition with patients

Dietary changes can be helpful in preventing or treating a variety of prevalent health problems. Physicians can be helpful in helping patients make positive dietary changes, be physically active and lose weight, but, for a variety of reasons, many physicians do little nutrition counseling. There is a need for brief, user-friendly tools to enable physicians to rapidly and accurately assess patients' diets and exercise habits as well as provide information to aid the physician in delivering effective nutrition counseling. The purpose of this paper is to discuss two new tools, WAVE and REAP, that have been developed by the Nutrition Academic Award to help physicians and other health care providers conduct nutrition assessment and counseling with their patients in a practical and effective manner. The WAVE acronym and tool is designed to encourage provider/patient dialogue about the pros and cons of the patients' current status related to Weight, Activity, Variety and Excess. The Rapid Eating and Activity Assessment for Patients (REAP) is a brief validated questionnaire that is designed to aid providers in performing a brief assessment of diet and physical activity. An accompanying Physician Key aids the provider in discussing the patient's answers and counseling them appropriately. REAP and WAVE can be helpful tools to facilitate nutrition assessment and counseling in the provider office. Depending on patients' health priorities and how much time is available, these tools can be used in a variety of ways to discuss nutrition with patients during a clinical encounter in 1-9 min.

Nutrition counseling in the promoting cancer prevention in primary care study

BACKGROUND

Little is known about the influence of personal and practice-level factors on physicians' dietary counseling practices.

METHODS

Primary care physicians (n = 130) were surveyed regarding the frequency that they "ask" patients about their diet, "assess" patients' reasons for and against dietary changes, "advise" patients to eat less fat and more fiber, "assist" patients in changing their diet, and "arrange" a follow-up contact to discuss their diet. In addition, physicians were asked their personal dietary practices, counseling confidence, practice demographics, and medical specialty.

RESULTS

Physicians who (a) reported consistently avoiding dietary fat, (b) were more confident in their diet counseling abilities, and (c) were sole owners of their practice were more likely to counsel than physicians who were employees or part owners of the practice. For example, physicians who reported consistently avoiding dietary fat (50.7% of physicians) were 3.2 (95% CI: 1.3-7.9) times more likely to "ask" their patients about their diet and 3.5 (95% CI: 1.5-8.6) times likely to "advise" their patients to eat less fat and more fiber.

CONCLUSIONS

Given the strong and consistent effects of a physician's dietary pattern on their counseling practices, future studies should examine the impact of modifying a physician's diet on their patients' dietary behavior.

Direct observation of nutrition counseling in community family practice

BACKGROUND

Despite the large potential of dietary changes to reduce morbidity and mortality, the frequency, time spent, and factors associated with nutrition counseling in primary care are not well studied.

METHODS

In a cross-sectional study of 84 family physician practices in northeast Ohio, nutrition counseling was measured by direct observation on 2 days for all consecutive ambulatory visits. The frequency, time spent, and patient and visit characteristics associated with nutrition counseling were determined.

RESULTS

Among 138 family physicians, only 6% included nutrition counseling in the majority (>50%) of patient encounters. Among 3475 consecutive outpatient visits in adults, nutrition counseling occurred in 24% of all patient visits, 17% of visits for acute illnesses, 30% of chronic illness visits, and 41% of well-care visits. The average time spent on nutrition counseling was 55 seconds, ranging from <20 seconds to >6 minutes. Nutrition counseling occurred in 45% of visits for diabetes, 25% of visits for cardiovascular disease, 31% of visits for hypertension, 26% of prenatal visits, and 33% of visits by obese patients (body mass index >30). Nutrition counseling was more likely to occur during visits by patients who were older or had diabetes mellitus, during visits for well care or chronic illness, and during longer visits.

CONCLUSION

Despite considerable variability from physician to physician, nutrition counseling occurs in approximately one fourth of all office visits to family physicians. The observed efforts by family physicians to focus nutrition counseling on high-risk patients may increase its impact.

Osteoporosis prevention: pediatricians' knowledge, attitudes, and counseling practices

BACKGROUND

Strategies to prevent adult osteoporosis are best undertaken during childhood and adolescence, when the greatest amount of bone mineral density is acquired. This study examines pediatricians' knowledge and practices regarding osteoporosis prevention.

METHODS

One hundred eighty-seven primary care pediatricians from San Diego and Imperial Counties responded to a 44-item mailed survey that measured physician knowledge, attitudes, and practices regarding osteoporosis prevention.

RESULTS

Knowledge of U.S. RDA for calcium in children and adolescents was limited, with only 23.7 and 32.3% of pediatricians correctly identifying the recommended values for children and adolescents, respectively. Thirty-eight percent of respondents regarded osteoporosis prevention to be an important issue, and less than half reported that they counseled patients for osteoporosis prevention. Of those pediatricians who did perform osteoporosis counseling, the two most frequently cited motivators for counseling were that counseling is recommended by professional boards and having a personal or professional interest in osteoporosis prevention. The most commonly reported barriers to counseling were other issues taking greater priority and having insufficient time to undertake counseling for osteoporosis prevention.

CONCLUSIONS

Osteoporosis prevention should begin in childhood and adolescence. This study suggests that many pediatricians do not counsel patients to reduce osteoporosis risk, nor do they consider this an important issue. Furthermore, they may not have full knowledge about how to prevent osteoporosis.

Randomized trial of a "talking computer" to improve adults' eating habits

PURPOSE

To assess efficacy of an intervention delivered by an interactive, computer-controlled telephone system to improve individuals' diets.

DESIGN

Randomized controlled trial.

SETTING

Large multispecialty group practice.

SUBJECTS

Two hundred ninety-eight adults who were both sedentary and had suboptimal diet quality.

INTERVENTION

Weekly communication for 6 months via a totally automated, computer-based voice system. Among intervention group subjects, the system monitored dietary habits and provided educational feedback, advice, and behavioral counseling. Control group subjects received physical activity promotion counseling.

MEASURES

Daily intake of fruits, vegetables, red and processed meats, whole fat dairy foods, and whole grain foods estimated from a food frequency questionnaire.

RESULTS

Mean age 45.9 years, 72% women, 45% white, and 45% African-American. Among participants who completed diet assessments, compared with the control group, the intervention raised fruit intake a mean of 1.1 servings per day (95% confidence interval [CI] .4, 1.7). On a 0 to 100 global diet quality score combining all five food groups, intervention participants improved their mean score 9 (95% CI 4, 13) points more than in the control group. The intervention also raised dietary fiber intake 4.0 g/d (95% CI .1, 7.8) and decreased saturated fat, as a proportion of energy intake, by 1.7% (95% CI -2.7, -.7).

CONCLUSIONS

This computer-based telecommunications dietary behavior intervention helped improve participants' overall diet.

Implementing a dietary intervention in primary care practice: a process evaluation

OBJECTIVES

Physicians acknowledge the need to advise their patients about dietary habits, but they may not have the training or tools to do this efficiently. In the context of a randomized trial, we investigated the feasibility of enlisting physicians to implement a dietary intervention in the primary care setting.

METHODS

Physicians from 14 primary care practices were assigned via randomization to introduce a self-help booklet to promote dietary change at routine appointments. Delivery of the booklet was recorded by these intervention physicians at the clinic appointment; intervention participants were asked 3 months later in a telephone interview about whether they received and used the booklet.

RESULTS

According to physician documentation, 95% of intervention participants who kept an appointment (n = 935) received the booklet; among participants completing a 3-month interview (n = 890), 96% reported the same. However, only about 50% of participants reported receiving the booklet from their physician; the remainder received the booklet from other clinic staff. Overall, 93% reported reading at least part of the booklet. Use of the booklet varied little whether it was delivered by a physician or staff person, but it was more likely to be read as time spent discussing the booklet increased.

CONCLUSIONS

Physician cooperation and evidence of intervention effectiveness support the use of primary care for the delivery of interventions to change diet; training the entire health team and repeating dietary advice at subsequent visits may improve the success of such interventions.

Incorporation of lean red meat into a National Cholesterol Education Program Step I diet: a long-term, randomized clinical trial in free-living persons with hypercholesterolemia

OBJECTIVE

Clinicians often recommend that intake of all meat, particularly red meat, be reduced in conjunction with a low-fat, low-cholesterol diet to reduce low-density lipoprotein (LDL) cholesterol. This study was designed to determine the long-term effects of lean red meat (beef, veal and pork) compared to lean white meat (poultry and fish) consumption on lipoprotein concentrations in free-living hypercholesterolemic subjects consuming a National Cholesterol Education Program (NCEP) Step I diet.

METHODS

A randomized, crossover design was utilized. Hypercholesterolemic men and women (LDL cholesterol between 3.37 and 4.92 mmol/L) (triglycerides <3.96 mmol/L) (n = 145) were counseled to consume > or =80% of their 170 g/d meat intake as either lean red meat or lean white meat for two 36-week phases, separated by a four-week washout period of free meat selection. Subjects were instructed to follow an NCEP Step I diet throughout the study.

RESULTS

There were no significant differences in lipid concentrations between the lean red meat and lean white meat phases. LDL cholesterol was 4.02+/-0.04 (SEM) and 4.01+/-0.04 mmol/L in the white and red phases, respectively; this represented a decrease of approximately 2% from baseline concentrations (p < 0.01). Total cholesterol also declined by 1% from baseline (p < 0.05), and high-density lipoprotein (HDL) cholesterol rose over the study period by approximately 2% to approximately 3% from baseline to reach concentrations of 1.37+/-0.03 mmol/L and 1.38+/-0.03 mmol/L in the white and red phases, respectively (p < 0.001). Triglycerides were not altered by treatment.

CONCLUSIONS

Consumption of lean red meat or lean white meat, as part of an NCEP Step I diet, is similarly effective for reducing LDL cholesterol and elevating HDL cholesterol concentrations in free-living persons with hypercholesterolemia.

Weight loss counseling by health care providers

OBJECTIVES

This study explores the pattern of weight loss counseling by health care providers in Connecticut and the associated weight loss efforts by patients.

METHODS

Data from the 1994 Connecticut Behavioral Risk Factor Surveillance System survey were analyzed to determine (1) the frequency of weight management counseling by health care providers of overweight adults with and without additional cardiovascular risk factors and (2) the current weight loss practices of overweight subjects.

RESULTS

Only 29% of all overweight respondents and fewer than half with additional cardiovascular risk factors, reported that they had been counseled to lose weight.

CONCLUSIONS

The findings suggest a need for more counseling of overweight persons, especially those with cardiovascular disease risk factors.