A randomised controlled trial on the effectiveness of a primary health care based counselling intervention on physical activity, diet and CHD risk factors

Abstract

Objective

The aim of the study was to determine if multiple patient-centred lifestyle counselling sessions would be of interest to patients at risk of coronary heart disease (CHD), in a primary care setting, and if such sessions would result in changes in physical activity and diet, and health status. A randomised trial was conducted to compare the counselling intervention with usual care (health promotion leaflet), among 334 mostly obese patients.

Methods

Patients were randomised into an intervention group that received standard exercise and nutrition information plus up to five face-to-face counselling sessions with a Physical Activity Specialist (PAS) and Registered Dietitian (RD) over a 6-month period or to a control group that only received the standard information.

Results

Of those invited, patients randomised tended to be more obese, older and female. The mean (S.D.) sessions attended was 2.0 (1.6) with 50% attending at least 3. At 6 months, the counselling group were more active, particularly with respect to walking, and had reduced weight, blood pressure and cholesterol, but had not changed their diet, compared with the control group. Furthermore, those who did more sessions had greater increases in activity and reductions in weight, blood pressure and cholesterol.

Conclusion

Attending multiple sessions of client-centred counselling in primary care was of interest to patients, and generally reduced CHD risk factors.

Practice implications

The primary care setting can be used effectively to promote particularly walking, using physical activity specialists and dietitians trained to use an adapted motivational interviewing (MI) counselling style.

Introduction

The global prevalence of obesity is increasing with major implications for a range of diseases such as Type 2 diabetes, heart disease, cancer [1], [2], [3] and fatigue-related problems [4], with major economic implications for society [5]. Even small changes in diet (by reducing fat consumption and increasing fruit and vegetable intake) and physical activity have been shown to reduce disease risk by up to 50% [6], [7], [8] through the prevention of a positive energy balance [9]. Primary care interventions that target both diet and energy expenditure (and not necessarily fitness) are therefore considered to be most effective for obesity management, and are at least as cost-effective as drug therapy and surgery [5]. However, the most effective way to facilitate small changes in multiple health behaviours within the primary health care setting is less clear and further research is needed [10].

Research involving primary care lifestyle counselling interventions, involving physical activity promotion, has tended to focus on changing single behaviours with just a few exceptions [11], [12], [13], [14], [15], at least in terms of how the results have been reported [16]. One good reason for this is to establish specificity in the link between an intervention (e.g., physical activity promotion) and outcome (e.g., change in physical activity). Pragmatically, patients may be interested in changing diet or physical activity or both, but it is not known how such preferences are manifested where both a dietitian and physical activity specialist advisor are available, for multiple consultations.

Traditional advice giving can create resistance to change among patients especially if it is focused towards behaviour change for which there is little or no readiness to change [17]. In contrast, motivational interviewing (MI) is a client-centred counselling approach that enables patients to explore their beliefs about their health (and associated attributions) and be guided towards self-generated solutions for positive changes in health behaviours [18], [19] Patients in primary care appear to have a preference for a patient-centred approach to consultations rather than more directive advice giving [20].

There is evidence that MI interventions are generally effective for behaviour change; and reducing coronary heart disease (CHD) risk factors in health care settings, but the quality of research has been generally poor and most trials have taken place in North America [18], [21], [22]. Some studies have not included objective measures of behaviour (e.g., by accelerometer) or biological measures (of CHD risk factors), which provided a threat to external validity. Also, studies showing less effectiveness have typically involved minimal intervention intensity (e.g., a single 15 min session with a patient), delivered by health care providers (rather than a physician), and involvement of generally healthy participants [22], [23], [24], [25]. Further research is needed to explore the effectiveness of multiple sessions of MI targeted at multiple health behaviour change, delivered by health care providers, and involving patients with greater CHD risk. Objective biological measures in such research would also help to verify the effectiveness of MI on changing CHD risk.

The present study therefore had several aims: (1) to determine the uptake of consultations with a Physical Activity Specialist (PAS) and Registered Dietitian (RD), in a primary care based trial, and the CHD risk factors associated with attendance. (2) To determine the effects of an MI-based intervention on CHD risk factors (i.e., diet, physical activity, body mass index (BMI), weight, blood pressure and cholesterol), among patients with one or more cardiovascular risk factors. (3) To determine the effects of number of counselling sessions attended on any change in CHD risk factors.