Patient Education and Counseling 90 (2013) 155–169
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Review
Nutrition and physical activity guidance practices in general practice: A critical review Sonja M.E. van Dillen a,*, Jaap J. van Binsbergen b, Maria A. Koelen c, Gerrit J. Hiddink a a
Strategic Communication, Wageningen University, Wageningen, The Netherlands Department of General Practice, Radboud University Medical Centre, Nijmegen, The Netherlands c Health and Society, Wageningen University, Wageningen, The Netherlands b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 May 2012 Received in revised form 17 September 2012 Accepted 6 October 2012
Objective: The aim of this critical review is to provide insight into the main outcomes of research on communication about nutrition and/or physical activity between GPs and patients for prevention or treatment of overweight and obesity. Methods: Relevant studies were identified by a computerized search of multiple electronic databases (MEDLINE, PsycINFO) for all available papers between 1 January 1995 and 1 January 2012. In addition, two independent reviewers judged all studies on ten quality criteria. Results: In total, 41 studies were retrieved. More studies were found about the guidance of obese patients than of overweight patients. The most common weight guidance practice was discussion of weight. The range of communication strategies for nutrition showed to be more diverse than for physical activity. Twelve studies were considered as high-quality studies, 18 were having medium quality, and 11 were seen as low quality. Conclusion: We reflected on the fact that the content of advice about nutrition and physical activity was quite general. GPs’ provision of combined lifestyle advice to overweight and obese patients seems to be rather low. Practice implications: Observational research is needed to unravel the quality of the advice given by GPs to overweight and obese patients. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: General practice Obesity Diet Exercise Health education Prevention and control Review
1. Introduction Evidence is emerging that the prevalence of overweight and obesity is increasing worldwide at an alarming rate [1]. In the Netherlands, almost half of the population is overweight [2]. Poor diet and physical inactivity increase the risk of several health problems, including obesity. These findings have led to the development of multiple recommendations about nutrition [3–5]. According to the Dutch Dietary Guidelines for example, consumers are recommended to eat a balanced diet, be sufficiently physically active every day, eat plenty of vegetables, fruits and whole grains products, eat (fatty) fish regularly, limit saturated fatty acids and trans fatty acids, limit intake of foods and drinks with added sugars, reduce sodium intake, and moderate alcohol intake [4]. Also several recommended guidelines about physical activity have been developed, that range from at least 30 min of
* Corresponding author at: Strategic Communication, Wageningen University, P.O. Box 8130, 6700 EW Wageningen, The Netherlands. Tel.: +31 317 482551; fax: +31 317 486094. E-mail address:
[email protected] (Sonja M.E. van Dillen). 0738-3991/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2012.10.022
moderate-intensity physical activity on five or more days of the week to 20 min of vigorous-intensity on three or more days of the week [6–8]. Recommended guidelines can be delivered by general practitioners (GPs) to their patients. GPs are ideally placed to promote healthy nutrition and physical activity. Patients perceived GPs as the most reliable source of nutrition information [9,10] or physical activity information [11]. The percentage of overweight and obese individuals seen in general practice even exceeds the percentage found in the general population [12]. Apart from the general guidelines about nutrition and physical activity, specific guidelines for the identification and management of obesity have been developed for health professionals [13–15]. These guidelines may offer GPs recommendations to support their daily guidance practices. However, it is not known to what extent GPs actually guide their patients on nutrition and/or physical activity to prevent or treat overweight and obesity. Understanding of their specific guidance practices used in daily practice is needed in order to develop appropriate interventions for overweight in the general practice, and to highlight these in medical education. Therefore, the aim of this critical review is to provide insight into the main outcomes of research on communication about
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nutrition and/or physical activity between GPs and patients for prevention or treatment of overweight and obesity. The following research questions will be answered: What is known about the main outcomes of studies conducted regarding GPs’ (nutrition and/or physical activity) guidance practices in order to prevent or treat overweight or obesity? What is known about the extent to which GPs integrate both nutrition and physical activity guidance practices into prevention or treatment of overweight and obesity? What are the specific nutrition and/or physical activity communication strategies of GPs in their management of overweight and obesity? What can be noticed about the study quality of these studies? 2. Methods 2.1. Search strategy Relevant studies were identified by a computerized search of multiple electronic databases (MEDLINE, PsycINFO) with EBSCOhost as resource for all available papers between 1 January 1995 and 1 January 2012. Moreover, we systematically screened the reference lists of (review)articles for other potentially relevant papers. The search strategy was based on the combination of five different categories, which had the following keywords in the title or abstract: 1. GP (general practitioner or family doctor or primary care physician or GP or PCP or general practice); 2. Patients with overweight or obesity (weight or overweight or obesity or adiposity or corpulence or obese or adipose); 3. Nutrition (nutrition or food or diet); 4. Physical activity (physical activity or exercise or physical fitness); 5. Communication (communication or guidance or counseling or education or promotion or advice or information or prevention or treatment or management or control or strategies or practices or preventive behaviors). 2.2. Inclusion criteria A study was included if: The study was written in English. The study was an original paper. The study addressed GPs’ nutrition guidance practices, physical activity guidance practices, or combination with the aim to prevent or treat overweight or obesity. A study was excluded if: The study was a review. The study provided insight into knowledge, attitudes, task perceptions or self-efficacy toward guidance practices, but not on guidance practices itself. The study addressed guidance practices in children. The study was about guidance practices of other health professionals in general practice, such as nurse practitioners or practice nurses. The study was conducted among GP trainees or residents. The study concerned medical therapy. The study was an intervention study.
The main reviewer (SvD) selected the studies on the basis of the above-mentioned inclusion criteria. The second reviewer (GJH) independently checked whether these studies indeed met these criteria. 2.3. Assessment of methodological quality The following data were extracted from the studies: country, study design, sample, response rate and main outcomes of the studies with respect to weight guidance practices, nutrition guidance practices and physical activity guidance practices. Next, two reviewers (SvD and GJH) independently assessed the study quality of the selected studies. The studies were judged on the following quality criteria: Clear description of study aim (e.g. consistency in research questions, measurement instrument, results and conclusions); Appropriate size of study population (e.g. report of the rationale for sample size); Sound selection of study population (e.g. random, stratified); Representative sample (e.g. no over-representation of female GPs, no over-representation of older GPs); Good response rate (e.g. 80% for phone or face-to-face interviews, 50% for mail questionnaires or classroom papers, 30 for Internet questionnaires) or low refusal rate/drop-out; Efforts were undertaken to optimize response rate (e.g. personalized letters, postage paid return envelope, reminders, incentives/gifts, simple and short measurement instrument, inclusion of group new respondents); Measurement instrument was well-developed (e.g. based on validated measures, prior research or reviewed literature); Measurement instrument was tested before use (e.g. pilot-test, pre-test for clarity, test–retest); Appropriate measurement instrument (e.g. distinguishable answer categories, Likert scales); Suitable report of study limitations and shortcomings (e.g. to overcome bias). In total, ten plusses could be assigned. Studies with eight plusses or more were considered as high quality studies. Studies with five, six or seven plusses were seen as medium quality, and studies which obtained less than five plusses were considered as low quality studies. 2.4. Theoretical framework The 5A’s Model was chosen as theoretical framework to guide our research questions. The 5A’s Model [16] includes five components, namely: 1. Assess: ask about/assess behavioral health risks and factors affecting choice of behavior change goals; 2. Advise: give clear, specific, and personalized behavior change advice, include information about personal health harms and benefits; 3. Agree: collaboratively select appropriate treatment goals and methods based on patient’s interest in and willingness to change behavior; 4. Assist: use behavior change techniques (self-help and/or counseling), aid patient in achieving agreed-upon goals by acquiring skills, confidence, and social/environmental supports for behavior change, supplemented with medical treatments when appropriate; 5. Arrange: schedule follow-up contacts to provide on-going assistance and to adjust treatment plan as needed, including referral to more intensive or specialized treatment.
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3. Results 3.1. Review process Fig. 1 outlines the method of article selection. A total of 182 studies were identified in the electronic literature search. Review of these abstracts however revealed that 173 articles did not met our criteria. Reference lists of collected (review)articles were screened for potentially relevant papers, resulting in another 32 articles. Finally, in total 41 studies about this topic were retrieved for this review and judged on its quality. Main characteristics of the studies are summarized in Table 1, divided into country, study design, sample and response rate. More than half of the studies found was performed in the last five years. Table 1 also shows the main outcomes and study quality for studies about weight guidance practices (W), nutrition guidance practices (N) and physical activity guidance practices (PA). 3.2. Main characteristics Of the 41 studies included in this review, 17 were conducted in the USA. Fifteen studies were done in Europe, of which six in the UK. Seven studies were performed in Australia and two in Asian countries. All studies in this review were cross-sectional studies, except for the longitudinal study of McAlpine and Wilson [17]. GP selfreports were the most common research method, especially mail questionnaires were often used. Moreover, about 20% of the selected studies was based on patient recall and the same percentage was found for chart audits. Six studies objectively measured weight guidance by means of direct observation. Six studies used a combination of research methods, such as selfreport and chart audit. One study evaluated patient–physician agreement on discussing weight, nutrition and physical activity. This study showed that patients and GPs did not agree about whether weight was reported for 39% of the visits [18]. Samples varied between 15 in a study with qualitative interviews and 13,859 in a Pan-European survey. Response rates ranged from 26% to 96%. 3.3. Weight guidance practices Table 1 shows that there were more studies about the guidance of obese patients than of overweight patients. A limited number of
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studies also considered severe obese patients. A couple of studies addressed three degrees of obesity. The most common weight guidance practice appeared to be discussion of weight. There were a couple of studies, in which body weight was actually measured, mostly by body mass index (BMI). Medication for weight loss was seldom recommended. Furthermore, several lifestyle recommendations were part of their weight guidance practices, including nutrition and physical activity promotion. 3.4. Nutrition and/or physical activity guidance practices In total, 36 out of 41 studies included nutrition guidance practices, and 35 out of 41 physical activity guidance practices. Remarkably, all studies performed in the last five years incorporated physical activity guidance practices. Table 1 shows that the frequency of nutrition guidance practices was often higher than that of physical activity guidance practices. The studies of Kreuter et al. [19] and Booth and Nowson [20] were the only ones, which specifically asked for the combination of receiving advice for diet plus exercise against diet only and exercise only. 3.5. Specific nutrition and/or physical activity communication strategies There were many different communication strategies reported. In one of the studies [21], GPs reported up to 25 weight loss strategies. The following 14 specific strategies related to nutrition to reduce weight were communicated: reduce consumption of fast food, reduce portion sizes, reduce soda consumption, eat a lowcalorie diet, decrease the fat content of the diet, consume breakfast, refer to a dietician for individual counseling, use fat and/or calorie modified foods, follow a specific calorie goal, eat a modified lowcarbohydrate diet (i.e.,
