Communication Study
The content of diet and physical activity consultations with older adults in primary care

https://doi.org/10.1016/j.pec.2014.03.020Get rights and content

Abstract

Objective

Despite numerous benefits of consuming a healthy diet and receiving regular physical activity, engagement in these behaviors is suboptimal. Since primary care visits are influential in promoting healthy behaviors, we sought to describe whether and how diet and physical activity are discussed during older adults’ primary care visits.

Methods

115 adults aged 65 and older consented to have their routine primary care visits recorded. Audio-recorded visits were transcribed and diet and physical activity content was coded and analyzed.

Results

Diet and physical activity were discussed in the majority of visits. When these discussions occurred, they lasted an average of a minute and a half. Encouragement and broad discussion of benefits of improved diet and physical activity levels were the common type of exchange. Discussions rarely involved patient behavioral self-assessments, patient questions, or providers’ recommendations.

Conclusions

The majority of patient visits include discussion of diet and physical activity, but these discussions are often brief and rarely include recommendations.

Practice implications

Providers may want to consider ways to expand their lifestyle behavior discussions to increase patient involvement and provide more detailed, actionable recommendations for behavior change. Additionally, given time constraints, a wider array of approaches to lifestyle counseling may be necessary.

Introduction

Healthy diet and sufficient physical activity have significant health and quality of life benefits across ages [1], [2] and generally result in lower healthcare utilization and associated costs [3]. While the benefits are greater if positive health behavior changes take place earlier in life, advantages still exist if changes begin in later years [4], [5]. Even small behavior improvements may result in significant health benefits [6].

As individuals reach age 65, women have an average of 20.3 and men an average of 17.6 years of life remaining, allowing for sufficient time for changes in dietary intake and physical activity levels to have an effect on functional status and quality of life [7]. Unfortunately, despite well documented benefits of engaging in healthy lifestyles, poor diet and physical inactivity are pervasive across ages, particularly among older adults. In the US, only 30.0% of adults ages 65 and older consume five or more fruits/vegetables a day [8] and 32.7% of adults ages 65 and over report no leisure time physical activity within the past 30 days [9]. Among older adults age 65 and over in the United States, self-reported rates of moderate physical activity participation range from 39.3% to 51.2%, depending on the criteria used [10], [11], and only 10% of adults over the age of 65 engage in any vigorous physical activity [12].

One potential venue for addressing these suboptimal health behaviors is through primary care providers. Primary care providers are particularly well situated to counsel older adults because older Americans are the largest consumers of health care services [7]. Adults between the ages of 65–74 average 6.5 physician office visits per person per year; adults ages 75 and over make 7.7 visits per person per year [13]. In 2008, 44% of visits for adults ages 65 and over were to primary care providers [14]. While fewer than 8% of these visits are dedicated preventive care visits, this frequent contact creates opportunities for lifestyle counseling [13].

Prior research indicates that provider counseling has the potential to help patients with dietary and physical activity changes [15], [16]. Currently however, there is very little research that documents how often these discussions occur with older patients or the nature of the counseling that occurs. The scant existing research indicates that diet and physical activity discussions occur in less than a quarter of primary care visits [17], though these estimates pertain to a general adult population rather than to older adults. Stange et al. (2002) found that the average duration of diet and physical activity discussions was 1.35 min, reduced to only .7 min when also taking into account visits during which prevention counseling did not occur [18]. Eaton, Goodwin, and Stange (2002) found that the average duration of dietary counseling was 55 s, ranging from less than 20 s to over 6 min [19]. Preventive service delivery is often associated with related signs or symptoms, suggesting that illneses care may present opportunities for prevention [20]. Flocke, Kelly, and Highland (2009) found that most prevention discussions occurred in the context of structured routines (e.g., checklists) or opportunistic triggers (symptoms or conditions) [21]. Anis and colleagues (2004) determined that most (61%) lifestyle counseling was physician-initiated [22].

Surprisingly little research has examined the actual content of lifestyle counseling. Sciamanna and colleagues (2004) conducted a study where all participating physicians were instructed to counsel their patients on physical activity, but the content of that counseling was left up to them [23]. The most common topics physicians counseled on were type of activity recommended, reasons to become active, and past experiences with activity. Action items – such as written plans or making plans for future discussion – were very uncommon. To rectify this sparse knowledge base regarding provider lifestyle counseling, we seek to describe whether and how diet and physical activity are discussed during older adults’ primary care visits.

Section snippets

Eligibility and recruitment

Providers and patients from the departments of Internal Medicine and Family and Community Medicine in an academic medical center were recruited and consented to have their visits audio-taped. The consent form indicated that the research study was focused on lifestyle behaviors, but did not specify diet and physical activity. Providers included attending physicians, nurse practitioners, physician assistants, resident physicians, and medical students. Patients over the age of 65 were identified

Description of the care context

Patients spent an average of 11.5 min with the provider with whom their visit was scheduled and an average of 26.6 min when including resident physicians with whom the visit was not scheduled and medical students. Twenty-eight percent of patients were accompanied during their visit, typically by spouses or adult children. Patients reported being very satisfied with the quality of their care, providing an average quality rating of 9.5 out of 10. Patients reported seeing their providers on average

Discussion

We designed this study to fill the gaps in our understanding of the frequency and nature of health behavior recommendations with older adults in the primary care setting. The findings indicate that diet and physical activity discussions between older adults and their primary care providers occur much more frequently than suggested by prior research. This nearly three-fold greater rate of diet and physical activity discussion may, in part, reflect our more inclusive identification process.

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