Review and Special article
Counseling to promote a healthy diet in adults: A summary of the evidence for the U.S. Preventive Services Task Force

https://doi.org/10.1016/S0749-3797(02)00580-9Get rights and content

Abstract

Objective

The purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings.

Design and data sources

We conducted a MEDLINE search from 1966 to December 2001.

Study selection

We included randomized controlled trials of at least 3 months’ duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease.

Data extraction

One author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques.

Data synthesis

We identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes.

Conclusions

Moderate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.

Introduction

D . iseases associated with unhealthy dietary behavior rank among the leading causes of illness and death in the United States.1, 2 Major diseases in which diet plays a role include coronary heart disease, some types of cancer, stroke, hypertension, obesity, osteoporosis, and non-insulin-dependent diabetes mellitus.1 All of these diseases are major causes of morbidity and mortality in this country.3 Although diet is associated with multiple health outcomes, the ability of counseling to change dietary patterns and improve health is unclear. In this report, counseling is defined as a cooperative mode of interaction between the patient and primary care physician or related healthcare staff members to assist patients in adopting behaviors associated with improved health outcomes.4

To address the question of whether counseling can improve dietary patterns, we performed an extensive systematic evidence review on behalf of the U.S. Preventive Services Task Force (USPSTF).1 This larger report comprehensively updated the chapter on dietary counseling from the second edition of the Guide to Clinical Preventive Services,5 and it is available from the Agency for Healthcare Research and Quality (AHRQ) at http://www.preventiveservices.ahrq.gov.

In 1996, the USPSTF recommended counseling adults and children older than 2 years to limit intakes of saturated fat and cholesterol, to maintain caloric balance in diets, and to emphasize foods that are high in fiber.5 An updated recommendation,6 dealing specifically with the question of dietary counseling, accompanies this summary of the evidence and is also available at http://www.preventiveservices.ahrq.gov.

Section snippets

Methods

We searched the MEDLINE database for randomized controlled trials (RCTs) published between 1966 and December 2001 that examined the effectiveness of counseling in changing dietary behavior. Search terms are provided in Appendix A. We supplemented our searches by reviewing the bibliographies of included articles and querying experts in the field during an extensive peer review process.

We included only studies that had been conducted with patients similar to those found in primary care practices

Results

We identified a total of 129 abstracts for review from our literature searches. After review of the 129 abstracts, we identified 74 articles that reported on examining the effect of counseling on dietary behavior. After full article review, we excluded an additional 49 articles from our analysis because they did not meet our eligibility criteria. Reasons for exclusion are provided in Appendix B.

We retained 21 studies reported in 25 articles that met our eligibility criteria.10, 11, 12, 13, 14,

Discussion

Researchers have used a wide range of interventions to examine the effect of behavioral counseling on dietary patterns among predominantly healthy adult patients. Among the studies we identified, low-intensity interventions in unselected primary care adult patients produced small or medium changes in self-reported dietary outcomes. Medium- to high-intensity interventions generally produced medium or large changes in dietary behavior, but these studies were generally conducted either in adult

Acknowledgements

This study was developed by the RTI—University of North Carolina Evidence-based Practice Center (UNC EPC), under contract to the Agency for Healthcare Research and Quality (Contract No. 290-97-0011), Rockville, MD. We acknowledge the assistance of David Atkins, MD, MPH, Chief Medical Officer of the AHRQ Center for Practice and Technology Assessment, and Jean Slutsky, PA, MSPH, the Task Order Officer, for their advice and counsel throughout this project. Finally, we thank our RTI-UNC EPC

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