A randomised controlled trial on the effectiveness of a primary health care based counselling intervention on physical activity, diet and CHD risk factors
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.
Section snippets
Participants and recruitment
Approval was obtained from the local NHS Research Ethics committee and Research Governance committee. Participants were drawn from a patient electronic database at a local health centre. Inclusion criteria were: aged 18–65 years, and at least one of the following CHD risk factors; excess weight (BMI of 28 or more), hypertension (SBP/DBP at least 150/90 mmHg) or hypercholesterolemia (at least 5.2 mmol/L). A BMI of 28 or more (rather than the conventional 30) was used because this was the desired
Results
A total of 334 patients completed the baseline assessment, of whom 203 were randomised to the counselling and 131 to the control condition. Table 1 provides details of patient recruitment bias. Those entering the trial were older, more likely to be female, have a higher BMI, and a lower SBP and cholesterol.
Almost all of those recruited (99%) were overweight at baseline. Furthermore, 79% of patients were obese (BMI ≥ 30). The second most prevalent CHD risk factor was hypercholesterolemia.
Discussion
Few studies have attempted to change both physical activity and diet, with the opportunity for patients to attend multiple counselling sessions with either a Physical Activity Specialist and/or a Registered Dietitian in the primary care setting. The present study showed that almost one-third of patients with elevated CHD risk were interested in such an intervention, with less interest from hypertensives and slightly greater interest from older women, as suggested in other studies (e.g., Ref.
Acknowledgements
The authors would sincerely like to thank the following: (1) Eastbourne Downs Primary Care Trust who provided the funding to support the study; (2) the staff at Princes Park Health Centre; (3) the members of the Trial Steering Group; and (4) the participants who willingly took part in the project.
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