Article
Multiple behavioral risk factor interventions in primary care: Summary of research evidence

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Abstract

Background

An important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner.

Methods

We review the evidence for interventions that separately address lack of physical activity, an unhealthy diet, obesity, cigarette smoking, and risky/harmful alcohol use, and evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature.

Results

There is evidence for the efficacy of interventions to reduce smoking and risky/harmful alcohol use in unselected patients, and evidence for the efficacy of medium- to high-intensity dietary counseling by specially trained clinicians in high-risk patients. There is fair to good evidence for moderate, sustained weight loss in obese patients receiving high-intensity counseling, but insufficient evidence regarding weight loss interventions in nonobese adults. Evidence for the efficacy of physical activity interventions is limited. Large gaps remain in our knowledge about the efficacy of interventions to address multiple behavioral risk factors in primary care.

Conclusions

We derive several principles and strategies for delivering behavioral risk factor interventions in primary care from the research literature. These principles can be linked to the “5A's” construct (assess, advise, agree, assist, and arrange-follow up) to provide a unifying conceptual framework for describing, delivering, and evaluating health behavioral counseling interventions in primary healthcare settings. We also provide recommendations for future research.

Introduction

Lack of regular physical activity, an unhealthy diet, smoking, and alcohol misuse are leading causes of disease, death, and loss of functioning.1, 2 Healthy People 2010 has designated tobacco use, physical activity, substance abuse, and overweight/obesity as four of the leading health indicators that will be closely monitored to reflect the health of the United States.1

Primary care clinicians have the potential to play an important role in addressing these key behavioral risk factors in the general population. For example, data from the 2000–2001 U.S. National Health Interview Survey indicate that 83% of the adults aged 18 to 64 years report that they have a usual source of care, a place where they usually go when they are “sick or ... need advice about health.”3 Moreover, the longitudinal nature of primary care provides multiple opportunities for clinicians to provide health behavior advice and counseling over long periods of time. According to recent data from a national sample of patients, >40% of patients aged >40 have had the same doctor for >5 years.4 Because a majority of adults in the United States have at least two of the four leading risk behaviors (see articles in this supplement by Fine et al.5 and Coups et al.6), strategies for addressing multiple risk behaviors within primary care settings are clearly needed. However, an important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner.7, 8

Although there is increasing evidence for the effectiveness of brief primary care–based interventions for changing individual health risk behaviors (e.g., tobacco use, risky drinking),9 few research trials in primary care settings have attempted to address multiple behavioral risk factors in a single intervention.10 In this paper, we will first review the evidence for interventions that separately address these four health behaviors in primary care settings. Then, because of the dearth of research evidence on multiple behavioral risk factor interventions in general populations of patients, we will review evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature. This is followed by suggestions for principles for delivering multiple behavioral risk factor interventions in primary care settings based on extrapolations from single risk factor evidence, the limited evidence from multiple behavioral risk factor interventions and other current data. We conclude with recommendations for future research.

Section snippets

What do we know about single behavioral risk factor interventions in primary care?

The United States Preventive Services Task Force (USPSTF), which relies on rigorous systematic evidence reviews demonstrating high-quality evidence of clinically significant benefits on health outcomes to recommend clinical preventive services,11 has recently published revised recommendations and associated systematic reviews addressing physical activity,12, 13 dietary counseling,14, 15 obesity,16, 17 smoking,18 and risky and harmful drinking.19, 20 To address smoking, we also utilized the

What do we know about multiple behavioral risk factor intervention trials in healthcare settings?

In order to review evidence available for multiple behavioral risk factor interventions in healthcare settings, we searched for systematic reviews published between 1990 and the present (2004) in MEDLINE, Cochrane Library, and the Database of Abstracts of Reviews of Effects (DARE). Systematic reviews were chosen because they generally define a systematic process for selection and evaluation of studies included, with quality of the studies taken into account in conclusions. We used the following

Summary of the evidence

To address the health needs of the nation, there is clearly a mandate to focus on four key behavioral risk behaviors: lack of regular physical activity; unhealthy diet/obesity; smoking; and risky/harmful alcohol use. Our review of the evidence indicates that there are evidence-based single behavioral risk factor interventions that primary care clinicians can employ to reduce smoking18, 21 and risky/harmful alcohol use19, 20, 44, 45 in unselected patients. These efficacious interventions include

Limitations of the existing evidence

A limitation of much of the research we have reviewed for this paper is reliance on results obtained among the subset of patients who are willing to participate in controlled clinical trials. This is especially true when testing interventions that require enrolled patients to undergo repeated demanding assessments and participate in intensive interventions over long periods of time. It is particularly problematic to compare effect sizes across studies that vary in the demands placed on subjects

Recommendations: principles to guide intervention

As noted in the epidemiologic papers in this supplement by Fine et al.5 and Coups et al.,6 a majority of individuals are at risk from more than one of the four behavioral risk factors that are the focus of this review. It is not reasonable to expect clinicians in primary care settings to deliver unique interventions for each of these four behavioral risk factor independently of the others, or independent of the long list of other preventive services that primary care clinicians are urged to

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    Preparation of this article was supported by a grant from The Robert Wood Johnson Foundation. We gratefully acknowledge the input and feedback provided by all members of the Planning Committee of the Addressing Multiple Behavioral Risk Factors in Primary Care Project.

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