As physicians prioritize the time they spend with patients, they're putting less emphasis on counseling activities

Physicians are missing opportunities to counsel patients already at risk of developing heart disease about the health benefits of improved diet and exercise, according to research from the Stanford University School of Medicine.

In a study that tracked the results of physician office visits between 1992 and 2000, the researchers found that diet counseling was provided in less than 45 percent of visits and exercise counseling was provided in less than 30 percent of visits with patients who had at least one condition that increased their likelihood of developing heart disease.

"This is clearly a population that would benefit from exercise and diet counseling, and yet these services aren't being provided at an optimal level," said Randall Stafford, MD, PhD, assistant professor of medicine at the Stanford Prevention Research Center and senior author of the study published in the October issue of Preventive Medicine.

Despite a wealth of evidence that better diet and exercise habits can help reduce the risk of heart disease, Stafford said he believes physicians feel they lack the tools and training to provide effective lifestyle counseling to their patients. Additionally, he said the current health-care environment aggravates the problem by giving doctors paltry reimbursement for counseling activities while making it financially attractive to prescribe medications or procedures.

"Even in those instances where medications are necessary, the guidelines for doctors still suggest that patients be encouraged to watch their diet and exercise," Stafford said. "Our study shows that there are many missed opportunities in which doctors could reinforce those messages."

Cardiovascular disease affects one in five Americans and remains the No. 1 cause of death in this country. It also carries a hefty price tag, racking up health-care expenditures estimated at $209 billion in 2003. Research over the years has shown that key risk factors associated with heart disease - including hypertension, diabetes, obesity and high cholesterol - can be modified through lifestyle changes that include healthier diets and adequate levels of exercise.

Stafford and his colleagues wanted to know whether physicians were actively encouraging their patients to make diet and exercise changes in accordance with guidelines established by such organizations as the American Heart Association. To answer the question, they examined two large databases - one that tracks services provided during visits to office-based physicians and a second that surveys hospital outpatient departments. The databases gave the researchers access to the types of services provided during 20,000 to 45,000 patients visits per year throughout the country.

The researchers specifically looked at visits with patients who had one or more risk factors for heart disease and found that diet and exercise counseling went up during the period being studied. In 1992, diet counseling was provided during 30 percent of the visits and exercise counseling was provided during 15 percent of the visits. By 2000, the rates had increased to about 45 percent for diet counseling and 30 percent for exercise counseling. "It's clearly a good thing that counseling is increasing, but the rate of counseling likely to be given on any one visit is still less than desirable," Stafford said.

The researchers also looked to see whether a patient's race, age or gender made a difference and found that it wasn't really a factor, though lifestyle counseling was provided less often to patients over the age of 75. That may point to a belief on the part of physicians that counseling isn't effective with older patients, Stafford said. But because diet and exercise changes can have dramatic effects in a relatively short amount of time, "there isn't a whole lot of reason not to treat a 75 year old as aggressively as a 50 year old," he added.

He said the study suggests that as physicians prioritize the time they spend with patients, they're putting less emphasis on counseling activities. One possible explanation is that physicians feel they don't have the training or the tools to provide diet and exercise guidance that will have a lasting effect on their patients, he said.

Additionally, reimbursements from health insurance companies often lead doctors to keep visits as brief as possible so that they can see more patients each day, making it difficult to offer meaningful counseling. "The skills involved in talking with patients are largely undervalued in the health-care system, while activities that have to do with procedures or prescribing tend to be valued to a greater extent," Stafford said.

He also expressed hope that patients would invest more effort in diet and exercise changes rather than focusing on medications to help control their risk factors. "Optimal management of these risk factors requires a good deal of work on the part of the patient. It's not as simple as taking a prescription."

Stafford's co-authors include first author Jun Ma, MD, PhD, and research assistants Guido Urizar, PhD, and Tseday Alehegn.