ArticleMultiple behavioral risk factor interventions in primary care: Summary of research evidence☆
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
References (146)
- et al.
Prevalence of multiple chronic disease risk factors2001 National Health Interview Survey
Am J Prev Med
(2004) - et al.
Physician screening for multiple behavioral health risk factors
Am J Prev Med
(2004) - et al.
Provider education to promote implementation of clinical practice guidelines
Chest
(2000) - et al.
Evaluating primary care behavioral counseling interventionsan evidence-based approach
Am J Prev Med
(2002) - et al.
Synthesis of lessons learned from cardiopulmonary preventive interventions in healthcare practice settings
Ann Epidemiol
(1997) - et al.
Current methods of the U.S. Preventive Services Task Forcea review of the process
Am J Prev Med
(2001) - et al.
Counseling to promote a healthy diet in adultsA summary of the evidence for the U.S. Preventive Services Task Force
Am J Prev Med
(2003) - et al.
Developing the Guide to Community Preventive Services—overview and rationale. The Task Force on Community Preventive Services
Am J Prev Med
(2000) - et al.
The effectiveness of interventions to increase physical activity. A systematic review
Am J Prev Med
(2002) - et al.
Behavior change intervention research in healthcare settings
a review of recent reports with emphasis on external validity. Am J Prev Med
(2002)
The alcohol use disorders identification testan aid to recognition of alcohol problems in primary care patients
Prev Med
Addressing multiple risk behaviors in primary carescreening issues and related concepts
Am J Prev Med
The effectiveness of disease and case management for people with diabetes. A systematic review
Am J Prev Med
Predictive value of lipid profile of salutary coronary angiographic changes in patients on a low-fat diet and physical activity program
Am J Cardiol
Reduction in sudden deaths by a multifactorial intervention programme after acute myocardial infarction
Lancet
Effects of cardiac rehabilitation after myocardial infarctionchanges in coronary risk factors and long-term prognosis
Am Heart J
Effect of diet and smoking intervention on the incidence of coronary heart disease. Report from the Oslo Study Group of a randomised trial in healthy men
Lancet
The Oslo Studydiet and antismoking advice. Additional results from a 5-year primary preventive trial in middle-aged men
Prev Med
Diet and exercise are equally effective in reducing risk for cardiovascular disease. Results of a randomized controlled study in men with slightly to moderately raised cardiovascular risk factors
Atherosclerosis
Oslo Study Diet and Antismoking Trial. Results after 102 months
Am J Med
Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction
Lancet
Healthy people 2010
Actual causes of death in the United States, 2000
JAMA
Health, United States, 2003
Room for improvement: patients report on the quality of their health care
Does the chronic care model serve also as a template for improving prevention?
Milbank Q
Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force
Ann Intern Med
Behavioral counseling in primary care to promote physical activityrecommendation and rationale
Ann Intern Med
Behavioral counseling in primary care to promote a healthy dietrecommendations and rationale
Am J Prev Med
Screening and interventions for obesity in adultssummary of the evidence for the U.S. Preventive Services Task Force
Ann Intern Med
Screening for obesity in adultsrecommendations and rationale
Ann Intern Med
Counseling to prevent tobacco use and tobacco-caused disease: recommendation statement
Screening and behavioral counseling interventions in primary care to reduce alcohol misuserecommendation statement
Ann Intern Med
Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adultsa summary of the evidence for the U.S. Preventive Services Task Force
Ann Intern Med
Treating tobacco use and dependence, clinical practice guideline
Improving primary care for patients with chronic illness
JAMA
A social-ecologic approach to assessing support for disease self-managementthe Chronic Illness Resources Survey
J Behav Med
Increasing physical activity. A report on recommendations of the Task Force on Community Preventive Services
MMWR Recomm Rep
Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke
Am J Prev Med
Counseling to promote a healthy diet
Clinical guidelines on the identification, evaluation and treatment of overweight in adults: the evidence report
The prevention and treatment of obesity
Eff Health Care
Periodic health examination, 1999 update1. Detection, prevention and treatment of obesity. Canadian Task Force on Preventive Health Care
CMAJ
Guide to clinical preventive services
Patient referral to a smoking cessation programwho follows through?
J Fam Pract
Integrating individual and public health perspectives for treatment of tobacco dependence under managed health carea combined stepped-care and matching model
Ann Behav Med
Strategies for reducing exposure to environmental tobacco smokeincreasing tobacco-use cessation and reducing initiation in communities and health-care systems
MMWR Recomm Rep
Screening for alcohol problems in primary carea systematic review
Arch Intern Med
The Alcohol Use Disorders Identification Test (AUDIT)a review of recent research
Alcohol Clin Exp Res
Screening and brief interventions for alcohol use disorders in managed care settings
Recent Dev Alcohol
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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.