Counseling to Promote a Healthy Diet in Adults: Summary of the Evidence

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Table 1. Counseling to Reduce Dietary Fat: Study Descriptions

Author Year	Sample Population	Level of Risk	Baseline Patient Numbers	Retention Rate	Setting	Intervention and Control Group Counseling Provider and Resources	Intensity
Beresford et al., 1992¹⁰	Adult men and women in North Carolina, USA; 35% black	Unselected	Intv: 120 Cont: 122	79%	Primary care	Intv: RN on-site provided 5 min intro to self-help materials with phone F/U 10 d later Cont: no intervention	Low
Beresford et al., 1997¹¹	Adult men and women in family practice clinics, USA	Unselected	Intv: 1,010 Cont: 1,111	86%	Primary care	Intv: trained MD-delivered 3 min intro to self-help booklet; reminder letter from MD Cont: NR	Low
Campbell et al., 1994¹² Tailored msg vs. control	Adult men and women of family practices: 2 urban and 2 rural in North Carolina, USA	Unselected	Intv: NR Cont: NR	82%	Mailings and computer-generated messages	Intv: Self-administered surveys in office delivered by staff; tailored messages mailed home Cont: self-administered surveys only; no messages	Low
Coates et al., 1999¹³	Post-menopausal women in research clinics of Women's Health Trial: 28% black, 16% Hispanic	At risk	Intv: 1,324 Cont: 883	75% to 85%	Research clinic	Intv: RD-delivered group sessions wkly for 6 wks, biweekly for 6 wks, monthly for 9 mo Cont: given Dietary Guidelines for Americans; no counseling	High
Delichatsios, Friedman et al., 2001¹⁴	Adult men and women in a large multisite, multispecialty group practice - Harvard Vanguard Medical Associates in Massachusetts, USA; 72% women, 45% white, 45% black	Unselected	NR	50%	Mailings and computer-generated messages	Intv: weekly diet-related educational feedback, advice, and behavioral counseling for 5-7 minutes by a totally automated, telephone-linked computer-based voice communication system Cont: weekly physical activity-related educational feedback, advice, and behavioral counseling for 5-7 minutes by a totally automated, telephone-linked computer-based voice communication system	Medium
Delichatsios, Hunt et al., 2001¹⁵	Adult men and women patients from 6 group HMO practices in the primary care research network of Harvard Pilgrim HealthCare, Massachusetts, USA	Unselected	Intv: 230 Cont: 274	Intv: 85% Cont: 92%	Mailings and computer-generated messages	Intv: mailed personalized dietary recommendations and 2 educational booklets; endorsement by trained (1 hour) MD or NP; 2 motivational phone counseling sessions by trained MPH student telephone counselors. RD consultation if needed. Cont: NR	Medium
Henderson et al., 1990¹⁶; Insull et al., 1990¹⁷; Kristal et al., 1992¹⁸; White et al., 1992¹⁹	Adult women 45-69 yrs at increased risk for breast cancer participating in Women's Health Trial in Ohio, Texas, Washington, USA	At risk	Intv: 448 Cont: 457	86%	Research clinic	Intv: RD delivered 8 group counseling meetings, followed by 4 meetings, then 20 monthly meetings Cont: no intervention	High
Keyserling et al., 1997²⁰	Adult men and women, low income w/ hypercholesterolemia in community and rural health centers North Carolina, USA	At risk	Intv: 184 Cont: 188	95%	Primary care	Intv: On-site MD (trained for intv in 1.5 hr) delivered diet assess and 3 sessions of 5-10 min counseling; followed up by referral to on-site (if available) or off-site RD if persistent hypercholesterolemia Cont: usual care	Medium
Knutsen and Knutsen, 1991²¹	Adult men at increased risk for CVD and their families Tromso, Norway	At risk	M: 1,373 F: 1,143 C: 2,838	M: 77% F: 82% C: 39%	Research clinic	Intv: MD and RD each made 1 home visit for CHD risk factor diet assessment and counseling Cont: NR	Medium
Kristal et al., 2000²²	Adult men and women enrollees of Group Health Cooperative of Puget Sound HMO, Washington, USA	Unselected	Intv: 729 Cont: 730	86.5%	Mailings and computer-generated messages	Intv: self-help materials, dietary analysis with behavioral feedback, and semi-monthly newsletters mailed home; trained health educator delivered one motivational phone call Cont: usual care - no intervention	Medium
Lindholm et al., 1995²³	Adult men and women at increased risk for CHD in 32 county health centers Lund, Sweden	At risk	Intv: 339 Cont: 342	Intv: 92% Cont: 95%	Primary care	Intv: usual health care advice from MD (see Cont) plus trained MD or RN delivered 6 group health care advice sessions which discussed 6 separate videos about 6 risk factors for heart disease Cont: usual health care advice from MD to reduce dietary fat, reduce weight if necessary, to stop smoking; pamphlet to reinforce instructions	High
Mojonnier et al., 1980²⁴	Adult men and women with hyperlipidemia in study centers, USA	At risk	Intv: NR Cont: NR	70%	Research clinic	Intv: RD and nutrition aids delivered 4 different multidimensional interventions including assessment, self-teaching or group-teaching or individual teaching, or multi-method Cont: followup at 6 or 9 mo for repeat measurements; no intervention	Medium
Neaton et al., 1981²⁵ (The MRFIT Study)	Adult men at increased risk for CHD: MRFIT Multicenter Study, USA	At risk	Intv: 5,825 Cont: 5,766	91%	Research clinic	Intv: 10 initial intensive sessions followed by counseling sessions approx. every 4 mo; provider NR Cont: 3 screenings plus annual risk factor measurement and medical exam	High
Ockene et al., 1996²⁶ and Ockene et al., 1999²⁷*	Adult men and women with hyperlipidemia in HMOs USA	At risk	Intv: NR Cont: NR	80%	Primary care	Intv: MDs (trained for 3 hr) delivered nutrition counseling and staff provided office support Cont: usual care	Medium
Roderick et al., 1997²⁸	Adult men and women with hypercholesterolemia in general practice from 4 regions, United Kingdom	Unselected	Intv: 473 Cont: 483	Intv: 86% Cont: 74%	Primary care	Intv: RNs on-site (trained for intv by RD) delivered dietary assessment, advice and F/U Cont: standard health education materials	Medium
Simkin-Silverman et al., 1995²⁹	Premenopausal women at research centers Pennsylvania, USA	Unselected	Intv: 267 Cont: 253	97%	Research clinic	Intv: Trained RD and behavioral interventionists led wkly group meetings x 10 wks then biweekly x 10 wks Cont: no intervention	High
Steptoe et al., 1999³⁰	Adult men and women at increased risk for CHD in 20 general practices in London, England	At risk	Intv: 316 Cont: 567	59%	Primary care	Intv: RN trained (4 days) in behavioral counseling delivered 2 to 3 individual counseling sessions-20 minutes each and 1 or 2 phone F/U Cont: NR	Medium

* total baseline participants = 1,162, not divided by groups.

Note: C indicates males and females combined; Cont indicates control; F, females; F/U, followup; Intv, intervention; M, males; msg, message; NR, not reported; RD, registered dietician.

Table 1. Counseling to Reduce Dietary Fat: Study Outcomes

Author Year	Main Outcome^a	Baseline Values	Duration of Followup	Final Followup Values	Change from Baseline to Final Followup	Net Difference in Change^b or Difference at Final Followup	P-value	Relative Change^c	Effect Size^d
Beresford et al., 1992¹⁰	Grams of total fat	Intv: 66 g Cont: 67 g	3 mo	NR	NR	3.8 g	NR	6%	Small
Beresford et al., 1997¹¹	% calories as total fat	Intv: 37.6% Cont: 37.5%	12 mo	NR	Intv: -1.5% Cont: -0.3%	1.2%	P <0.01	3%	Small
Campbell et al., 1994¹² Tailored msg vs. control	Grams of saturated fat	Intv: 18.7 g Cont: 16.3 g	4 mo	Intv: 13.9 g Cont: 15.8 g	Intv: -4.8 g Cont: -0.5 g	4.3 g	P = 0.036	26%	Large
Campbell et al., 1994¹² Tailored msg vs. control	Grams of total fat	Intv: 45.6 g Cont: 41.1 g	4 mo	Intv: 35.3 g Cont: 39.8 g	Intv: -10.3 g Cont: -1.3 g	9 g	P = 0.033	22%	Large
Coates et al., 1999¹³	% calories as saturated fat	Intv: 13.2% Cont:12.9%	18 mo	NR	Intv: -4.4% Cont: -0.9%	3.5%	NR	27%	Large
Coates et al., 1999¹³	% calories as total fat	Intv: 39.7% Cont: 39.1%	18 mo	NR	Intv: -14.1% Cont: -2.5%	11.6 %	NR	30%	Large
Delichatsios, Friedman et al., 2001¹⁴	% calories as saturated fat	Intv: 10.1% Cont: 10.3%	6 mo	Intv: 8.8% Cont: 10.5%	Intv: -1.3% Cont: +0.2%	1.5%	P <0.05	15%	Medium
Delichatsios, Hunt et al., 2001¹⁵	% calories as saturated fat	Intv: 10.6% Cont: 10.3%	3 mo	Intv: 9% Cont: 9.7%	Intv: -1.6% Cont: -0.6%	1.0%	NR	10%	Small
Henderson et al., 1990¹⁶; Insull et al., 1990¹⁷; Kristal et al., 1992¹⁸; White et al., 1992¹⁹	% calories as saturated fat	Intv: 13.8% Cont: 13.6%	24 mo	Intv: 7.2% Cont: 12.3%	Intv: -6.6% Cont: -1.3%	5.3 %	P <0.001	39%	Large
	% calories as total fat	Intv: 39.1% Cont: 38.9%	24 mo	Intv: 22.6% Cont: 36.8%	Intv: -16.5% Cont: -2.1%	14.4 %	P <0.0001	37%	Large
Keyserling et al., 1997²⁰	Dietary risk assessment score (scale: 0 to 98)	Intv: 22.0 Cont: 22.0	12 mo	NR	Intv: -5.3 Cont: -2.0	3.3	P <0.001	15%	Medium
Knutsen and Knutsen, 1991²¹	% of subjects using butter for cooking	NR	6 yrs	Intv: M: 20% F: 20% Cont: M: 36% F: 36%	NR	M: 16% F: 16% C: 10%	NR	NA	Medium
Kristal et al., 2000²²	Fat score: 1 to 4 1 = low fat 4 = high fat	Intv: 2.29 Cont: 2.30	12 mo	Intv: 2.20 Cont: 2.30	Intv: -0.09 Cont: 0.00	0.09	P <0.001	4%	Small
Lindholm et al., 1995²³	Grams of total fat	NR	18 mo	NR	NR	14.6 g	P <0.001	NA	Medium
Mojonnier et al., 1980²⁴	% calories as saturated fat	Intv: 13.9% Cont: 13.3%	6 and 9 mo F/U combined	Intv: 10.5% Cont: 12.8%	Intv: -3.9% Cont: -0.5%	3.4%	P <0.001	26%	Large
Mojonnier et al., 1980²⁴	% calories as total fat	Intv: 37.8% Cont: 36.3%	6 and 9 mo F/U combined	Intv: 33.9% Cont: 36.6%	Intv: -3.9% Cont: +0.3%	4.2%	P <0.01	12%	Large
Neaton et al., 1981²⁵ (The MRFIT Study)	% calories as saturated fat	Intv: 14.0% Cont:14.0%	3 yrs	Intv: 10.0% Cont: 13.5%	Intv: -3.9% Cont: -0.4%	3.5%	NR	25%	Large
Neaton et al., 1981²⁵ (The MRFIT Study)	% calories as total fat	Intv: 38.3% Cont: 38.2%	3 yrs	Intv: 33.8% Cont: 38.0%	Intv: -4.5% Cont: -0.2%	4.3%	NR	12%	Large
Ockene et al., 1996²⁶ Ockene et al., 1999²⁷	% calories as saturated fat	Intv: 10.7% Cont: 10.7%	12 mo	NR	Intv: -1.1% Cont: 0%	1.1%	P = 0.01	10%	Small
Ockene et al., 1996²⁶ Ockene et al., 1999²⁷	% calories as total fat	Intv: 30.7% Cont: 31.2%	12 mo	NR	Intv: -2.3% Cont: -0.7%	1.6%	P = 0.11	5%	Small
Roderick et al., 1997²⁸	% calories as saturated fat	Intv: 13.7% Cont: 14.0%	12 mo	NR	Intv: -1.5% Cont: -0.6%	0.9%	NR	6%	Small
Roderick et al., 1997²⁸	% calories as total fat	Intv: 34.3% Cont: 34.2%	12 mo	NR	Intv: -2.4% Cont -0.9%	1.4%	NR	4%	Small
Simkin-Silverman et al., 1995²⁹	% calories as saturated fat	Intv: 12.3% Cont: 11.8%	6 mo	NR	Intv: -4.3% Cont: -0.4%	3.9%	P <0.001	33%	Large
Simkin-Silverman et al., 1995²⁹	% calories as total fat	Intv: 36.1% Cont: 35.5%	6 mo	NR	Intv: -11.1% Cont: -1.0%	10.1%	P <0.001	28%	Large
Steptoe et al., 1999³⁰	DINE Fat score	Intv: 30.5% Cont: 28.2%	12 mo	Intv: 23.4 Cont: 23.9	Intv: -7.1 Cont: -4.3	2.8%	P <0.05	10%	Medium

^a Outcomes in this table are reported in the following order of preference depending on the data available from each study: (1) percentage of calories from saturated or total fat; (2) grams of saturated or total fat; and (3) other methods of measuring change in diet as presented by the authors of specific studies.
^b Baseline minus followup value for the intervention group minus baseline minus followup value for the control group.
^c Absolute change in the intervention group from baseline to followup divided by the baseline value of the control group.
^d Effect size categories are assigned based on (in order of preference) net difference in change, difference at final followup, or relative change.

Note: C indicates males and females combined; Cont indicates control; F, females; F/U, followup; Intv, intervention; M, males; msg, message; NA, not available; NR, not reported.

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