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Can Fam Physician
Vol. 54, No. 3, March 2008, pp.404 - 412
Copyright © 2008 by The College of Family Physicians of Canada
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Research

Which patients receive on diet and exercise?

Do certain characteristics affect whether they receive such advice?

Jennifer Sinclair
Medical student at Dalhousie University

Beverley Lawson, MSc
Senior Research Associate in the Primary Care Research Unit of the Department of Family Medicine at Dalhousie University

Fred Burge, MD FCFP MSc
Family physician and Research Director in the Department of Family Medicine at Dalhousie University in Halifax, NS

Correspondence to: Dr Fred Burge, Dalhousie University, Department of Family Medicine, Abbie J. Lane Bldg, 8th Floor, 5909 Veterans Memorial Lane, Halifax, NS B3H 2E2; telephone 902 473–4740; fax 902 473–4760; e-mailfred.burge{at}dal.ca

Chronic disease contributes substantially to morbidity and mortality in Canada. Physical activity (exercise) and healthy eating are key elements of disease prevention and health promotion. Exercise has been shown to reduce the risk of many chronic illnesses, including cardiovascular disease, hypertension, diabetes, obesity, and osteoporosis1–3; to reduce anxiety and stress; and to improve the chances of continued independent living in later life.2 Not eating enough fruit and vegetables is associated with obesity4 and development of chronic diseases, most notably cardiovascular disease and certain types of cancer.3

Although the many benefits of healthy eating and exercise have been well established, evidence of the effectiveness of physicians’ counseling on diet and exercise has been inconclusive. The Canadian Task Force on Preventive Health Care5 and the United States Preventive Services Task Force6,7 have both found insufficient evidence to recommend for or against counseling adults regarding exercise or diet in primary care settings. Evidence, however, does support intensive behavioural counseling on diet for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic diseases.6 The Primary Health Care Transition Fund, in response to recent health care reports, has supported improving strategies for prevention and management of chronic diseases in primary care.8–10

Existing studies show positive associations between receiving advice on diet or exercise from a physician and being a woman,11–14 being middle-aged,11–15 having a higher income,11 having a higher level of education,11,12,14 having many chronic diseases,11–16 reporting poor health,12,14 and frequently visiting a physician.13 There appears to be very little literature supporting our belief that good-quality primary health care, namely good doctor-patient communication, strong doctor-patient relationships, and how well doctors "enable" patients to care for themselves, is associated with giving patients advice on diet and exercise.17

The purpose of this study was to identify potential predictors of whether patients would receive advice on diet and exercise from their physicians by looking at patients’ characteristics, familiarity with the clinic, and selected perspectives of the quality of their primary health care, most notably the elements of patient-centredness (communication, doctor-patient relationships, and enablement). Determining such predictors would aid in the development, evaluation, and improvement of current preventive care strategies in primary health care renewal efforts.


   METHODS
TOP
 METHODS
RESULTS
 DISCUSSION
 Footnotes
 Acknowledgment
 References
 
Design and instrument
Data for this study were obtained from responses to the Primary Care Practice Survey (PCPS) administered in 2005 to 1607 residents of the Capital District Health Authority (CDHA) in Halifax, NS. The PCPS is an adaptation of the General Practice Assessment Questionnaire (GPAQ)18 and the former General Practice Assessment Survey19 enhanced by questions relevant to primary care in Canada. Development and evaluation of the PCPS were part of a larger project to assess the public’s experience with primary care in the CDHA. In brief, modifications and new questions agreed upon by an expert panel were pilot-tested on 376 CDHA residents, and the results were reviewed by panel members and focus groups composed of various stakeholders and consumers. Psychometric evaluation of the 2005 PCPS suggested that it had moderate to very good validity and reliability in the 6 primary care "domains" considered (access, continuity, communication, patient-provider relationships, enablement, and prevention). A report on the development of the survey and its psychometric properties is available on-line.20 Ethical approval for this study was received from the CDHA.

Subjects and sample
Potential participants were chosen systematically from a random selection of household telephone numbers in the CDHA. Age and sex quotas were set before the survey in order to obtain a representative distribution of respondents by sex and to obtain a preponderance of senior residents (65 years old and older), as required in the original study for effective subgroup analysis. A total of 1607 residents 18 years old or older participated in the survey. For this study, participants were eligible only if they reported having a regular family physician, so 45 participants became ineligible, leaving a final sample of 1562 respondents.

Measures
To investigate how frequently physicians gave advice on diet and exercise separately, 2 of 3 questions that made up the PCPS prevention scale were used. Subjects were asked: "In visits to your usual family doctor [health care provider], how often were the following subjects discussed with you: advice on healthy eating and advice on appropriate exercise for you." Four response options were provided (never, rarely, often, always) which were dichotomized for analysis into often or always and never or rarely. These questions had good face and content validity and good individual reliability coefficients in scale assessment (Cronbach {alpha} was 0.74 for diet, 0.72 for exercise, and 0.82 for the overall scale).20

Possible predictors included demographic characteristics (sex, age, geographic indicator, employment status, education, income, being a visible minority, self-reported health status, and total number of chronic illnesses), familiarity with the clinic (years as a patient, total number of visits during the past 12 months), and patients’ perspectives on the quality of their care. Perspectives on quality of care focused on 3 key indicators of patient-centredness: communication, patient-provider relationships, and enablement. Previously validated scales used in the PCPS were used to develop a score for patients’ perspectives on these 3 dimensions using methods suggested by the authors of the General Practice Assessment Questionnaire.18 Owing to the positively skewed distribution of the scores, each was dichotomized at a commonly shared cut point (< 75% versus ≥ 75%). Table 1 lists the dimensions assessed and the questions used to obtain scores for each of the scales included in this study.


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  		Table 1 Primary care attributes assessed in the 2005 Primary Care Practice Survey (PCPS) and questions used to derive scores for each of the PCPS scales included in our study Survey questions were adapted from the General Practice Assessment Questionnaire and the General Practice Assessment Survey.18,19

 
Analysis
All analyses were weighted to reflect the distribution of the population in the CDHA with respect to sex and age. Tests of association ({chi}2, Wilcoxon) were conducted between physicians’ giving advice on diet and exercise (often or always versus rarely or never) and respondents’ characteristics, familiarity with the clinic, and perspectives on the quality of their care. Unadjusted and adjusted logistic regression analyses were conducted to determine the odds of having often or always received advice about diet or exercise. Manual backward elimination techniques were used to identify factors independently associated with frequently receiving advice on diet and exercise. The final model included all independent factors statistically significant at P < .05. The Stata program was used to analyze the data.21


   RESULTS
TOP
 METHODS
 RESULTS
DISCUSSION
 Footnotes
 Acknowledgment
 References
 
Response rate was 68.4%. Associations between the characteristics of the 1562 respondents who reported having regular family physicians and whether they received advice on diet and exercise are shown in Table 2.


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  		Table 2 Respondents’ demographic characteristics, familiarity with the clinic, and perspectives on quality of care related to how frequently they received advice on diet or healthy eating and appropriate exercise {chi}2 and nonparametric tests of association used where applicable.

 
Advice on diet or healthy eating
About 37.6% of respondents reported often or always receiving advice from their physicians on diet or health eating. In bivariate analysis, sex, age, education, minority status, self-reported health, number of chronic illnesses, familiarity with the clinic, and the 3 perspectives on quality of care were significantly associated with receiving advice on diet or healthy eating (Table 2).

In the final multivariate model, only sex, age, self-reported health, total number of chronic illnesses, and patient-provider relationship and enablement scores were significantly associated with frequently receiving advice on diet (Table 3). After controlling for all other variables in the model, men, those aged 35 to 54, those with more chronic illnesses, and those with higher scores on patient-provider relationship and enablement scales were more likely to frequently receive advice on diet or healthy eating. Those reporting excellent health were less likely to receive such advice.


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  		Table 3 Likelihood of reporting often or always having received advice on diet or healthy eating

 
Advice on appropriate exercise
About 42% of respondents reported often or always receiving advice from their physicians on exercise. In bivariate analysis, with the exception of the geographic and visible minority indicators, all demographic characteristics were associated with receiving advice on appropriate exercise as were number of visits made to the clinic during the past 12 months and the 3 perspectives of quality of care.

After accounting for all other retained variables in the final multivariate model, sex, age, self-reported health status, number of chronic illnesses, and scale scores pertaining to communication and enablement remained independently related to frequently receiving advice on appropriate exercise (Table 4). Men, older adults, those reporting good health, those with many chronic illnesses, and those with higher scores on communication and enablement scales were all more likely to often or always receive advice on appropriate exercise.


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  		Table 4 Likelihood of reporting often or always having received advice on appropriate exercise

 

   DISCUSSION
TOP
 METHODS
 RESULTS
 DISCUSSION
Footnotes
 Acknowledgment
 References
 
Overall, sex, age, chronic illnesses, self-reported health status, and respondents’ perceptions regarding enablement were significantly associated with receiving advice on both diet and exercise. Respondents’ perceptions of their providers’ communication skills were associated only with receiving advice on exercise, while their perceptions of patient-provider relationships were associated only with receiving advice on diet.

Results from previous studies are conflicting with regard to whether men or women are more likely to receive advice on diet and exercise. Although many suggest that women are more likely than men to receive such advice,11–14 a very recent study of Australian residents supports our finding that men are more likely to receive advice.22 Both our analysis and those in the literature adjusted for the presence of other sex-specific issues, such as income, education, and number of chronic diseases. It seems there is no clear indication of whether men or women are more likely to receive advice on diet and exercise.

Our findings demonstrate that patients’ perspectives on the quality of their care are associated with whether they receive advice on diet and exercise. Higher scores on patient-provider relationship and enablement scales were associated with frequently receiving advice on diet while higher scores on communication and enablement scales were associated with frequently receiving advice on exercise. The single other study examining these specific relationships reported a strong association between patient-physician communication and counseling on healthy living (diet, exercise, substance abuse).17

Our results linking effective communication and strong patient-provider relationships with more frequent counseling on prevention, combined with published results associating counseling with positive health outcomes and healthy behaviour,23–27 suggest that we should consider communication and patient-provider relationships as essential components of health promotion and disease prevention. This study provides additional evidence that medical education programs and guidelines for improving existing health care teams should emphasize good communication skills and development of effective patient-provider relationships in order to improve counseling on diet and exercise.

Those receiving advice from physicians on diet and exercise in our study appear to be those in greatest need (ie, middle-aged adults with chronic diseases), suggesting a current focus on secondary, rather than primary, prevention. This trend might be overlooking the preventive potential of exercise and healthy eating or it might reflect the fact that, without good evidence of effectiveness, physicians are counseling only people at risk and not counseling those who are well. Primary health care renewal has emphasized the need for disease prevention and health promotion.8 By counseling primarily those at risk, we might be missing opportunities for health promotion and disease prevention. Unfortunately, the long-term benefits of counseling healthy patients have been difficult to ascertain. In addition, the realities of busy practices, poor reimbursement, and inadequate training have likely influenced physicians to focus their counseling on those in greatest need.28–32

We know that counseling on exercise and diet is effective for patients with certain chronic diseases, and our findings suggest that this counseling is indeed happening in the CDHA. Our results demonstrate that the more chronic illnesses patients have, the more likely they are to receive advice from their physicians.

Limitations
First, selection and recall bias are always potential problems in conducting telephone surveys. Respondents and nonrespondents could well differ in many ways, including in their perspectives on quality of care and in their recall of discussions with their physicians. It is possible our respondents failed to recall some discussions of diet and exercise. Second, the survey questions were limited in how well they captured the frequency of discussions on health promotion; they allowed only the responses often, always, rarely, or never. Questions did not assess the nature or quality of advice given, nor did they differentiate between discussions initiated by physicians and those initiated by patients. Third, survey questions did not allow us to ascertain whether patients were trying to lose weight or whether they had other factors that could influence discussion of diet and exercise. Finally, given that our results are derived from cross-sectional data, we cannot infer causality.

Conclusion
This study adds to the evidence connecting good-quality primary health care (good communication, good doctor-patient relationships, and effective enablement of patients) with more frequent preventive counseling regarding diet and exercise. In addition, we have provided evidence that indicates physicians are more likely to target advice at those with many chronic illnesses.

Clearly, there is a need for longitudinal studies examining the long-term effectiveness of counseling on diet and exercise for the general patient population in primary care settings. To our knowledge, ours is the only study that has included both patients’ characteristics and their perspectives on the quality of their care as independent variables in examining the possible predictors of receiving advice on diet and exercise.

Strategies to increase the frequency of receiving advice from physicians on diet and exercise would likely benefit from enhancing communication between patients and physicians, improving patient-provider relationships, and increasing the ability of health care providers to help their patients feel enabled to follow advice. Physicians should be aware of their counseling practices and consider the possibility of discussing healthy behaviour with patients with no obvious risk factors. This would be practising true primary prevention.



   EDITOR’S KEY POINTS
 
  • This study identifies potential predictors of whether patients receive advice from their physicians on diet and exercise.
  • Almost 38% of respondents reported often or always receiving advice from their physicians on healthy eating; 42% reported often or always receiving advice on exercise.
  • Men, those aged 35 to 54, those with more chronic illnesses, and those with higher scores on relationship with their health care providers and enablement scales were more likely to receive advice on diet. Those reporting excellent health were less likely to receive advice.

 



   POINTS DE REPÈRE DU RÉDACTEUR
 
  • Cette étude cerne les facteurs qui indiquent que les patients reçoivent des conseils de leur médecin sur l’alimentation et l’exercice.
  • Près de 38% des répondants ont déclaré recevoir souvent ou toujours des conseils de leur médecin sur une alimentation saine; 42% ont dit recevoir souvent ou toujours des conseils sur l’exercice.
  • Les hommes, les sujets de 35 à 54 ans, ceux qui avaient le plus de maladies chroniques, et ceux qui obtenaient les plus hauts scores sur l’échelle mesurant la relation avec leur équipe de santé et celle mesurant l’incitation à prendre sa santé en main étaient les plus susceptibles de recevoir des conseils sur l’alimentation. Ceux qui se disaient en excellente santé étaient les moins susceptibles de recevoir des conseils.

 


   Acknowledgment
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 Acknowledgment
References
 
This work was partially supported by a grant from the Nova Scotia Health Research Foundation and the Capital District Health Authority


   Footnotes
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
Acknowledgment
 References
 
Contributors

Ms Sinclair, Ms Lawson, and Dr Burge developed the original idea. Ms Sinclair and Dr Burge reviewed the literature. Ms Lawson and Ms Sinclair managed and analyzed the data. The first draft of the discussion was developed by Ms Sinclair and reviewed and edited by Ms Lawson and Dr Burge. All the authors saw and approved the final version of the manuscript.

Competing interests

None declared

This article has been peer reviewed.


   References
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 Acknowledgment
 References
 

  1. United States Department of Health and Human Services. Healthy people 2010: understanding and improving health. Washington, DC: US Department of Health and Human Services; 2000.
  2. Public Health Agency of Canada, Physical Activity Unit. Physical activity for health: the evidence. Ottawa, ON: Public Health Agency of Canada; 2003. Available from: www.phac-aspc.gc.ca/pau-uap/fitness/evidence.html. Accessed 2008 January 7.
  3. World Health Organization. Global strategy on diet, physical activity and health. Geneva, Switz: World Health Organization; 2003. Available from: www.who.int/dietphysicalactivity/publications/facts/pa/en/index.html. Accessed 2007 October 1.
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  8. Primary Health Care Transition Fund. Interim report. Ottawa, ON: Health Canada; 2005.
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