Wednesday, December 15, 2010

Healthy lifestyle counseling challenges

I once used to see patients in a clinical practice located next door to a popular fast food restaurant. My office hours usually began in the early afternoon and ended about 9 p.m.. Whenever I was pressed for time or hadn't packed a dinner, I'd run over to the restaurant to grab a burger, french fries, and soda, and many of my colleagues did the same. As we exchanged guilty looks while sneaking in through the back entrance of the office, I'd often find myself wondering if my counseling patients to eat healthier foods was actually making any difference.

The answer, it turns out, is both yes and no. In this week's issue of the Annals of Internal Medicine, Jennifer Lin (no relation) and her colleagues at Kaiser Permanente's Center for Health Research in Portland, Oregon reviewed the latest scientific evidence on how effective medical counseling really is in terms of getting patients to improve their eating and exercise behaviors. Their analysis, which included data from 73 studies, found that counseling does, in fact, help patients make changes that lead to modest improvements in their health. They were able to lose excess weight, increase their activity, and improve their blood pressure and cholesterol levels. While few studies followed patients for more than a year, one long-term study indicated that those with mildly elevated blood pressure who were extensively counseled on switching to a low-sodium diet had a reduced risk of heart attacks and heart failure 10 to 15 years later.

There is, though, a catch: The researchers found that in order to achieve these changes, patients needed far more counseling time than doctors or nurses can offer in our current healthcare system. "Low-intensity" counseling—a total of 30 minutes or less which is typical for most patients—appeared in the study to have no beneficial effect. Only "medium" (totaling up to six hours) and "high" intensity (more than six hours) counseling made a significant difference, and these sessions were typically led by specially trained health educators rather than the patients' own physicians who may not be as well trained in dispensing specialized nutrition or fitness advice. While study participants got these services for free, those patients in the real world often find that their health insurance will only pay for counseling if they have diabetes or heart disease.

In the absence of sweeping health insurance reforms—that were, unfortunately, not included in the Affordable Care Act—some people have suggested that closer monitoring of at-risk patients could potentially substitute for one-on-one interactions with health counselors. As I mentioned in a previous blog post, remote monitoring technology that transmits information such as blood pressure readings and weight measurements from the patient's home to the doctor's office has been shown in some studies to reduce hospitalizations for heart failure—but in others, it hasn't been found to help. In a multi-center randomized trial of more than 1600 heart failure patients recently published in the New England Journal of Medicine, patients who were instructed to use an interactive telephone voice-response system to provide daily information to their physicians about heart failure symptoms and weight were just as likely to die or be re-admitted to the hospital within 6 months than similar patients who received the usual care.

One explanation for these disappointing results is that nearly 1 in 7 patients who were instructed to use the monitoring system never made a single telephone call, and little more than half of the patients were still calling the system at least three times per week by the end of the study. It's possible that perhaps the outcomes could have been improved if the doctors in the study kept closer tabs on patients who weren't calling into the system. But maybe not, since these particular patients may have been just as reluctant to change their health habits in response to their worsening condition.

The bottom line is that there is no one-size-fits-all solution to changing health-related behaviors. What causes you to quit smoking, have a salad instead of a steak with all the trimmings, or start walking for 30 minutes a day, might not have any effect on someone else. As a family doctor, I see it as my job not only to advise my patients about what sorts of behaviors are good or bad for their health, but to work with them to learn what it will take to motivate them to make beneficial lifestyle changes. If there's a fast food restaurant next door to where they work, for example, I'd tell them to consider choosing what I finally did: Leave all their cash at home and force themselves to pack a meal instead.


The above post was first published on my Healthcare Headaches blog at