Elsevier

Preventive Medicine

Volume 39, Issue 4, October 2004, Pages 815-822
Preventive Medicine

Diet and physical activity counseling during ambulatory care visits in the United States

https://doi.org/10.1016/j.ypmed.2004.03.006Get rights and content

Abstract

Background. Research is limited regarding national patterns of behavioral counseling during ambulatory care. We examined time trends and independent correlates of diet and physical activity counseling for American adults with an elevated cardiovascular risk during their outpatient visits.

Methods. The National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) provided 1992–2000 national estimates of counseling practices in private physician offices and hospital outpatient departments.

Results. Rates of diet and physical activity counseling among visits by at-risk adults exhibited a modest ascending trend from 1992 to 2000, with the biggest growth found between 1996 and 1997. Throughout the 1990s, however, diet counseling was provided in <45% and physical activity counseling in ≤30% of visits by adults with hyperlipidemia, hypertension, obesity, or diabetes mellitus. Lower likelihood of either counseling was significantly associated with patients who were ≥75 years of age, seen by generalists, and those with fewer risk factors. Also, diet counseling was less frequently provided during visits by whites vs. ethnic minorities and by men vs. women.

Conclusions. Despite available national guidelines, diet and physical activity counseling remain below expectations during outpatient visits by adults with an elevated cardiovascular risk. Given recent trends, immediate, satisfactory improvement is unlikely without future innovative interventions.

Introduction

Cardiovascular disease (CVD) affects one in five Americans and contributes to substantial morbidity and mortality [1]. CVD remains the number one cause of death in the United States, regardless of gender and ethnicity, causing 709,894 deaths in 2000 [2]. As a result, CVD is associated with enormous health care expenditures, estimated at US$209 billion in 2003 [1]. The high prevalence and societal burden of CVD are closely associated with high rates of CVD risk factors. Many of these risk factors, including smoking, hypertension, diabetes mellitus, obesity, and hyperlipidemia, are preventable and modifiable [3]. Lifestyle modifications, such as engaging in healthy dietary patterns and adequate physical activity, are integral to the prevention and treatment of CVD and its risk factors [4], [5], [6], [7].

Lifestyle modifications can be approached via population-based national health initiatives, community-wide interventions, and patient-centered clinical services. For maximum effectiveness, clinical preventive services may require efforts and resources beyond the practice level to include the organization and community [8]. Nevertheless, individual physicians and other health providers undeniably share responsibility for promoting healthy behavior. Eighty percent of Americans cite their physician as their primary source of information about health, with the average adult making 2.7 visits to a physician per year [9]. Clinicians, particularly physicians, represent a credible source of health information for their patients, who in turn may be especially receptive to information about their health during clinic visits [10], [11]. Therefore, patient-centered clinical services present a unique opportunity to reinforce and complement other sources of health advice or information.

Various health organizations and agencies have devoted great effort to developing and disseminating clinical guidelines on behavioral counseling to promote healthy eating and active living [4], [12]. Some of these guidelines emphasize the importance of behavioral counseling for both primary and secondary prevention purposes, whereas others recommend that counseling efforts be aggressively pursued in high-risk patients because of greater cost-effectiveness [4], [6], [7], [13], [14], [15]. While the importance of behavioral counseling is virtually self-evident, its effectiveness in clinical settings warrants further research and improvement [8], [15], [16]. In particular, the effectiveness of counseling to promote physical activity and a healthy diet remains unknown in unselected primary care patients [15], [16].

Studies that examine physician practice regarding behavioral counseling have consistently suggested suboptimal adherence to clinical guidelines [17], [18], [19], [20], [21], [22], [23]. Several factors influence the implementation of behavioral counseling in clinical settings. The likelihood of counseling, for example, has been found to vary by nonclinical factors, such as patient demographics, payment source, geographic region, and physician specialty [24], [25], [26], as well as by clinical factors, with patients at greater risk for CVD more likely to receive behavioral counseling services [21], [22], [23], [24], [26]. A majority of past studies, however, are limited by their small sample sizes and/or inability to track changes over time.

Our primary aim is to examine national trends in the provision of diet and physical activity counseling in both private physician offices and hospital outpatient departments. We anticipate that counseling rates have increased over time. Our secondary aim is to examine the independent effects of patient and health provider characteristics (i.e., nonclinical factors) and patient CVD risk status (i.e., clinical factors) on counseling practices. In so doing, our goal is to identify patient subgroups that may particularly benefit from increased behavioral counseling.

Section snippets

Data sources

Data between 1992 and 2000 for this study were obtained from the National Ambulatory Medical Care Survey (NAMCS) and the Outpatient Department (OPD) component of the National Hospital Ambulatory Medical Care Survey (NHAMCS). NAMCS captures health care services provided by office-based physicians, while NHAMCS surveys practices in hospital outpatient departments. Both surveys, conducted by the National Center for Health Statistics (NCHS) in Hyattsville, MD [27], utilize multistage probability

Magnitudes and temporal trends

Rates of diet and physical activity counseling generally increased from 1992 to 2000, although fluctuations are evident in intermediate years (Fig. 1). In 1992, diet counseling was reportedly provided during 30% [99% confidence interval (CI): (28% 32%)] and physical activity counseling was reported during 17% (15% 19%) of total visits by at-risk adult patients. The rates of reported diet and physical activity counseling during visits by at-risk adults both increased significantly from 1996

Discussion

The persistently high prevalence of CVD and its modifiable risk factors in the United States suggests an imperative need for standard prevention and treatment practices. National data have shown increased prevalence of several CVD risk factors over the past decade. For example, obesity among U.S. adults has increased from 22.9% to 30.5% between 1988 and 2000 alone [29]. Several national guidelines have been developed to guide the prevention and treatment of modifiable CVD risk factors in

Acknowledgements

This study was supported by a research grant from Agency for Healthcare Research and Quality (AHRQ) (R01 HS11313-01).

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