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Lead Review Article July 2001: 197-215
Nutrition and Physical Activity Interventions to Reduce Cardiovascular Disease Risk in Health Care Settings: A Quantitative Review with a Focus on Women Sara Wilcox, Ph.D., Deborah Parra-Medina, Ph.D., Melva Thompson-Robinson, Dr.P.H., and Julie Will, Ph.D.
The authors conducted a quantitative literature re- view of the impact of 32 diet and physical activity (PA) interventions delivered in health care settings on cardiovascular disease risk factors. lnterven- tion effects were relatively modest but statistically significant for PA, body mass index or weight, di- etary fat, blood pressure, and total and low-den- sity lipoprotein serum cholesterol. lntervention effects were generally larger for samples with a mean age >50 years and for studies with <6 months follow-up. Type of comparison group, type of intervention, and use of a behavior theory did not have a consistent impact on intervention ef- fects. Few studies focused on persons of color, although the results from these studies are prom- ising.
Introduction
The U.S. Preventive Services Task Force’s Guide to Clini- cal Preventive Services, considered a “gold standard” for evidence-based recommendations for clinical preventive services,’ recommends that all healthy adults be coun- seled regarding diet and exercise. Healthy People 201 0,2 a nationwide health promotion and disease prevention
Dr. Wilcox is with the Department of Exercise Science, Norman J. Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA. Dr. Parra-Medina is with the Department of Health Promotion and Education, Norman J. Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA. Dr. Thompson-Robinson is with the Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA. Dr. Will is with the Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
agenda, has set the following goals for physical activity and dietary counseling: 85% of physicians will counsel their patients about physical activity (PA) by the year 20 10, and 75% of physician office visits made by patients with cardiovascular disease (CVD), diabetes, or dyslipidemia will include counseling or education related to diet and nutrition by the year 20 10.
These guidelines and goals are based on evidence that poor dietary habits and sedentary lifestyles contrib- ute to excessive morbidity and mortality: and that physi- cian counseling for diet and exercise is effective but not practiced often enough to have a significant i m p a ~ t . ~ Sed- entary lifestyle and poor nutrition are major risk factors for CVD, the leading cause of death for American men and ~ o m e n . ~ . ~
A number of reviews have documented the signifi- cant ability of physician counseling to effect general lifestyle changes,’ as well as to promote PA”’O and a health- ful diet.6 Since the publication of these reviews, however, a number of additional health care-based PA and dietary interventions have been conducted. Further, all reviews to date have been narrative reviews that have not exam- ined the magnitude of nutrition and PA counseling ef- fects. Finally, previous reviews have not highlighted gen- der and race/ethnicity issues. We were interested in the effects of these interventions for women, especially women of color.
This updated literature review focuses on dietary and PA counseling interventions delivered in health care set- tings that were aimed at reducing CVD risk factors. We only considered articles that were focused exclusively on women or that included women as participants. This re- view also quantified the magnitude of the interventions’ effects by computing effect sizes (correlation coefficients) for all studies. This review was conducted as part of the Heart Healthy and Ethnically Relevant Tools project in which our primary interest was dietary and PA interven- tions for CVD risk reduction in women in general, and in women of color in particular. Thus, a final purpose of this
Nutrition Reviews@, Vol. 59, No. 7 197
review was to highlight health care interventions con- ducted with women of color.
Methods
Search Strategy We searched four electronic databases for the years 1980- 2000: Medline, Cumulative Index to Nursing and Allied Health Literature, Current Contents Connect, and PsychINFO. The following key words were used for the diet search: nutrition or diet combined with counseling, blacks, African Americans, women, cardiovascular disease, hypertension, cholesterol, weight, family practice, and primary health care. The following key words were used for the physical activity search: exercise or PA combined with counseling, blacks, African Americans, women, phy- sicians, family practice, primary health care, intervention studies, randomized controlled trial, patient education, and health promotion. Because index searches have been shown to yield less than two-thirds of relevant articles,l‘*’* we also searched the bibliographies of original and review articles already retrieved.
Inclusion Criteria The review was restricted to English language reports of trials conducted in health care settings that investigated the effects of PA or dietary advice on CVD risk factors. Additional criteria for the studies included were: a CVD risk factor was included as an outcome variable (i.e., sys- tolic blood pressure [SBP], diastolic blood pressure [DBP], total serum cholesterol, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, body mass index [BMI, kg/m2] or body weight, dietary fat, energy intake, dietary fiber, PA, or exercise); the report was a primary study rather than a review or practice guide- line; the sample included women ages 2 18 years; the study was published between 1980 and 2000; and a control group or minimal-intervention group was included. Studies that focused on pharmacotherapy were not reviewed.
Computation of Effect Sizes In order to provide an index of the relative magnitude or clinical meaningfulness of the intervention effect, we com- puted effect sizes for all outcome variables specified by our search criteria. In essence, this procedure removes the scale of measurement (e.g., mm Hg, kcal) and converts all outcomes to a standard metric so that comparisons between effects from different studies are possible.
The Pearson Product Moment Correlation r was selected as our standard metric. The use of r was chosen over other metrics for three reasons articulated by R0sentha1.l~ First, studies often do not provide enough data to calculate an accurate effect size d. Second, r can be used to convert de- pendent t-tests to estimates of effect sizes, whereas d can- not. The third reason has to do with the simplicity of inter-
preting r in practical terms: methods exist for easily convert- ing r to an improvement in success rate associated with the intervention or treatment.I3
The computation of correlation coefficients was aided by the software program Meta-Analysis 5.3.14 The man- ner in which correlation coefficients were computed was generally dictated by the amount of information reported in the study. Often, we were required to compute or con- vert exact statistics (e.g., F, 1, x 2 ) or exact P values to r. A number of studies used within-subject variance to com- pute the differences in change between the control and intervention groups. In these cases, we essentially com- puted a dependent t-test and converted this value to r. When this was not the case and means and standard de- viations (or standard errors) were reported at baseline and follow-up, we subtracted the change in the control group’s score from the change in the intervention group’s score, divided this difference by the pooled standard deviation at baseline, and then converted this value to r. We used conventional formulas, as specified by RosenthalI3 and Wolf,’5 to compute correlation coefficients.
The correlation coefficient is a usehl indicator of clini- cal efficacy. It can be squared, and this value represents the variance in the outcome variable that is explained by intervention status. Thus, a correlation coefficient of 0.30 indicates that 9% of the variance in total serum choles- terol, for example, is explained by intervention status, and that 9 1 % (1 - 9) is explained by other f a~ t0 r s . l~
We further coded each correlation coefficient accord- ing to the type of CVD risk factor (PA or exercise, stage of readiness for change in PA, BMI or weight, dietary fat, energy intake, dietary fiber, general diet outcome, stage of readiness for change in diet, SBP, DBP, total, LDL or HDL serum cholesterol and potential moderating characteris- tics (age, behavior theory specified, type of intervention, comparison group, and follow-up period). We noted whether or not a study reported the use of a behavior theory (e.g., Social Cognitive Theory, Transtheoretical Model) to guide the intervention. Type of intervention was coded as diet-only, PA-only, or combined interven- tion.
Owing to a limited number of results for some of the CVD risk factors, we only examined moderating effects for PA or exercise, BMI or body weight, dietary fat, SBP, and total cholesterol. We did not compute correlation coeffi- cients that compared two or more distinct interventions (in the absence of a control or minimal intervention group).
Results
Summary of Articles A total of 45 health care-based intervention papers were reviewed and are included in Table 1. Of these, two did not report adequate data to compute correlation coefficients, five reported on an ongoing intervention or were descrip-
198 Nutrition Reviews@, Vol. 59, No. 7
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Set
tings
.-c 3
Phys
ical
Act
ivity
Inte
rven
tions
ii'
Bul
l et a
1.I9
Bul
l et a
1.2"
~~
5
Des
ign
&
Sett
ing
&
Dep
ende
nt
a
CD
stud
y Sa
mpl
e T
heor
y In
terv
entio
n FO
~~O
W-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
B
lair
et
RC
T
Prim
ary
care
I,
: Clin
icia
n &
hea
lth e
duca
tor
advi
ce
6 an
d 24
En
ergy
R
esul
ts n
ot y
et r
epor
ted
Res
ults
not
yet
rep
orte
d K
ing
et a
]."
n =
874
(U
nite
d St
ates
) I,: I
, + in
-clin
ic h
ealth
edu
cato
r m
onth
s ex
pend
iture
45
% w
omen
T
TM
, SC
T
coun
selin
g, i
nter
activ
e m
ail
and
fitne
ss
I,: I, +
2 y
ears
tel
epho
ne
-@
<
VI
29%
min
ority
35
-75
year
s co
unse
ling,
cla
sses
-9
M =
51
year
s 2
Bul
l and
R
CT
Fa
mily
pra
ctic
e C
: N
o in
terv
entio
n 1,
6, a
nd 1
2 Pe
rcen
t ac
tive
Mor
e pa
tient
s in
I w
ere
1 m
onth
= 0
.09
0
Jam
rozi
k'8
n =
763
(A
ustr
alia
) I:
Ver
bal
advi
ce f
rom
clin
icia
n an
d m
onth
s ac
tive
at 1
and
6 m
onth
s 6
mon
th =
0.0
9 -4
65%
wom
en
TT
M,
SCT
m
aile
d st
anda
rd o
r ta
ilore
d pa
mph
let
(do%
, 38%
) th
an p
atie
nts
12 m
onth
s =
0.0
5
0,
218
year
s M
= 5
0 ye
ars
RC
T
Fam
ily p
ract
ice
C:
No
inte
rven
tion
1, 6
, and
12
Perc
ent
activ
e A
t 1
mon
th,
31%
of
C,
1 m
onth
, I,
ver
sus
C =
0.0
7 n
= 7
63
(Aus
tral
ia)
I,: V
erba
l ad
vice
fro
m c
linic
ian
and
mon
ths
38%
of
I,, a
nd 4
1% o
f I,
1 m
onth
, I,v
ersu
s C
= 0
.10
65%
wom
en
TT
M,
SCT
m
aile
d ge
nera
l pa
mph
let
patie
nts
wer
e ac
tive.
At
6 6
mon
ths,
I, v
ersu
s C
= 0
.09
218
year
s 6
mon
ths,
I, ve
rsus
C =
0.0
6 M
= 5
0 ye
ars
12 m
onth
s, I,
ver
sus
C =
Se
dent
ary
mon
ths,
dif
fere
nces
0.
03
12 m
onth
s, I,
vers
us C
=
0.06
in C
(31
%, 3
0%)
(P <
0.02
). D
iffer
ence
s w
ere
NS
at
12 m
onth
s
1,: V
erba
l ad
vice
fro
m c
linic
ian
and
mai
led
tailo
red
pam
phle
t m
onth
s, 3
0%,
39%
, and
36
% w
ere
activ
e. A
t 12
wer
e NS
RC
T
Fam
ily m
edic
ine
C: U
sual
car
e 3
mon
ths
Cha
nge
in l
evel
of
Dif
fere
nces
bet
wee
n I,
vers
us C
= 0
.12
n =
272
(A
ustr
alia
) TT
M
I,: T
ailo
red
and
pers
onal
ized
mai
ling
activ
ity
grou
ps w
ere
NS.
All
grou
ps
I, v
ersu
s C
= 0
.08
83%
wom
en
I, ve
rsus
C =
0.1
1 21
8 ye
ars
M =
39
year
s U
nder
activ
e
I,: G
ener
al a
nd p
erso
naliz
ed m
ailin
g 1,:
Gen
eral
and
gen
eric
mai
ling
show
ed a
n in
crea
se i
n th
ese
varia
bles
at
FU
Prim
ary
care
C
: Pa
mph
let
on g
ood
heal
th p
ract
ices
24
mon
ths
Sede
ntar
y lif
esty
le
Gro
up a
ssig
nmen
t Pa
tient
s in
goo
d he
alth
=
64%
wom
en
exam
inat
ions
and
cou
nsel
ing
sess
ion
lifes
tyle
Pa
tient
s in
poo
r he
alth
=
13%
min
ority
0.
04
265
year
s
n =
255
84
% w
omen
St
ates
) TT
M,
SCT
mat
ched
mat
eria
ls;
IO-m
inut
e bo
oste
r w
alki
ng, h
ours
/ to
act
ive
stag
e (P
<O.
OOOl
). 28
% m
inor
ity
call;
opt
iona
l tip
she
ets
wee
k m
oder
ate-
I i
ncre
ased
wal
king
by
40
218
year
s in
tens
ity P
A m
inut
es,
C i
ncre
ased
M
= 3
9 ye
ars
Bur
ton
et a
L2'
RC
T
n =
309
7 (U
nite
d St
ates
) NR
I: O
ffer
ed t
wo
prev
entiv
e un
rela
ted
to s
eden
tary
-0
.00
Mul
tispe
cial
ty
C:
Usu
al c
are
46
wee
ks
Stag
e of
cha
nge,
52
% o
f I
patie
nts
vers
us
stag
e =
0.3
9 cl
inic
s (U
nite
d I:
Phys
icia
n co
unse
ling
and
stag
e-
min
utes
/wee
k 12
% o
f C
pat
ient
s m
oved
PA
ave
rage
= 0
.12
Cal
fas
et
QE
wal
king
by
10 m
inut
es
(P <
0.05
)
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Setti
ngs
(con
tinue
d)
Phvs
ical
Act
ivitv
Inte
rven
tions
~~
Des
ign
&
Sett
ing
8i D
epen
dent
St
udv
Sam
ple
Theo
rv
Inte
rven
tion
FO
~~O
W-U
D V
aria
bles
R
esu I
ts E
ffec
t Siz
e r
Gol
dste
in e
t aL2
’ Pi
nto
et a
].,,
Gra
ham
-Cla
rke
&
Old
enbu
rg2s
Har
land
et
Ker
se e
t a1
.2’
Lew
is a
nd L
ynch
2*
Mar
cus
et
RC
T
n =
355
65
% w
omen
3%
min
ority
M
= 6
6 ye
ars
RC
T
n =
758
26
% w
omen
18
-69
year
s
RC
T
n =
523
58
% w
omen
40
-64
year
s
RC
T
n =
267
54
% w
omen
26
5 ye
ars
M =
73.
5 ye
ars
RC
T
n =
396
77
% w
omen
21
8 ye
ars
M =
35.
5 ye
ars
QE
n
= 6
3 72
% w
omen
250
year
s M
= 6
1 ye
ars
Prim
ary
care
C
: Sta
ndar
d ca
re
6 w
eeks
, St
age
of c
hang
e,
At
6 w
eeks
, 89
% o
f I
wer
e 6
wee
ks s
tage
= 0
.19
(Uni
ted
Stat
es)
I: St
age-
mat
ched
phy
sici
an c
ouns
elin
g,
8 m
onth
s PA
SE
in p
repa
ratio
n or
act
ion
8 m
onth
s st
age
= -
0.12
SC
T, T
TM
, H
ET
wri
tten
PA p
resc
ript
ion,
pat
ient
man
ual,
FU a
ppoi
ntm
ent
with
phy
sici
an,
new
slet
ters
di
ffer
ence
s w
ere
NS.
PA
SE
vers
us 7
4% o
f C
pat
ient
s (P
<O.
OOl).
A
t 8
mon
ths,
scor
es i
ncre
ased
in b
oth
grou
ps a
t 6 w
eeks
, bu
t de
crea
sed
at 8
mon
ths
(bet
wee
n-gr
oup
diff
eren
ces
wer
e N
S)
6 w
eeks
PA
= -
0.02
8
mon
ths
PA =
0.0
1
Gen
eral
pra
ctic
e C
: C
linic
ian
CV
D r
isk
asse
ssm
ent
and
4 an
d 12
St
age
of c
hang
e,
From
bas
elin
e to
4 m
onth
s,
Pre-
Post
: (A
ustr
alia
) TT
M
feed
back
m
onth
s en
ergy
exp
endi
ture
m
ore
C p
atie
nts
prog
ress
ed
4 m
onth
s st
age
= -0
.14
12 m
onth
s st
age
= 0
.01
12 m
onth
s pr
e-po
st k
cal=
Insu
ffic
ient
dat
a re
porte
d to
com
pare
gro
ups
I,: C
+ p
atie
nt v
ideo
I,:
I, +
sel
f-he
lp b
ookl
et
to a
hig
her
stag
e (2
7%)
than
I, (
23%
) or
I, (1
7%)
(P <
0.05
). Fr
om b
asel
ine
0.16
to
12
mon
ths,
dif
fere
nces
be
twee
n gr
oups
wer
e N
S.
Ener
gy e
xpen
ditu
re
incr
ease
d in
the
ent
ire
sam
ple
over
the
12
mon
ths
(P <
0.00
1),
but
grou
p di
ffer
ence
s w
ere
NS
Gen
eral
pra
ctic
e (U
nite
d K
ingd
om)
com
mun
ity r
esou
rces
T
TM
C:
Prin
ted
heal
th i
nfor
mat
ion
and
I,: C
+ o
ne b
rief
MI
I,: I,
+ co
mm
unity
fac
ility
vou
cher
I,:
C +
six
inte
nsiv
e M
I I,:
I, +
com
mun
ity f
acili
ty v
ouch
er
I: G
eria
tric
heal
th e
duca
tiona
l pr
ogra
m
for
prac
titio
ner
Gen
eral
pra
ctic
e C
: Usu
al c
are
(Aus
tralia
) N
R
12 w
eeks
and
Se
ssio
ns o
f 12
mon
ths
mod
erat
e or
in
crea
sed
PA v
ersu
s 16
%
1 ye
ar,
I ve
rsus
C =
0.0
3 gr
eate
r PA
At
12 w
eeks
, 38%
of
I
of C
(P
<0.
001)
. A
t 1
year
, 26
% o
f I
vers
us 2
3% o
f C
in
crea
sed
PA (
NS)
12 w
eeks
, I
vers
us C
= 0
.19
12 m
onth
s Fr
eque
ncy
and
At
FU,
I w
alke
d 44
M
inut
es/w
eek
= 0
.13
dura
tion
of P
A m
inut
es/w
eek
mor
e th
an C
(P
<0.
05)
Fam
ily m
edic
ine
C:
Usu
al c
are
(but
=40
% r
ecei
ved
1 m
onth
M
inut
edw
eek
of
I in
crea
sed
by 1
08.7
M
inut
es/w
eek
= 0
.20
(Uni
ted
Stat
es)
NR
ex
erci
se a
dvic
e)
exer
cise
m
inut
es/w
eek
vers
us -
23.7
I:
2-3
min
utes
of
resi
dent
exe
rcis
e ad
vice
an
d ed
ucat
iona
l ha
ndou
t fo
r C
(P
<0.
01)
Prim
ary
care
C
: C
ompl
eted
the
stud
y pr
ior
to
1 m
onth
PA
SE
For
I, PA
SE s
core
s PA
SE =
0.1
4 (U
nite
d St
ates
) ph
ysic
ian
train
ing
sess
ion
incr
ease
d fr
om 1
48 to
154
T
TM
, SC
T
I: St
age-
mat
ched
phy
sici
an c
ouns
elin
g
mat
eria
ls,
and
I-m
onth
FU
vis
it of
fere
d
vers
us 1
25 t
o 12
5 fo
r C
(3
-5
min
utes
), w
ritte
n ed
ucat
iona
l (N
S)
2 s 2.
Phys
ical
Act
ivity
Inte
rven
tions
a St
udy
Sam
ple
Theo
ry
Inte
rven
tion
Follo
w-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
?
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Setti
ngs
(con
tinue
d)
g D
esig
n &
Se
ttin
g &
D
epen
dent
3
Nay
lor
et a
].]'
z v) 6 >
VI 2
Schu
lt2'
? u
Stev
ens
et a
]."
Swin
bum
et a
l.'?
Tayl
or e
t al.
,'
QE
n
= 2
94
77%
wom
en
M =
42.
4 ye
ars
RC
T
n =
54
37%
wom
en
<I%
m
inor
ity
36-6
5 ye
ars
M =
48.
8 ye
ars
RC
T
n =
714
60
% w
omen
13
% m
inor
ity
45-7
4 ye
ars
M =
59
year
s In
acti
ve
RC
T
n =
491
57
% w
omen
M
= 4
9 ye
ars
RC
T
n =
345
26
% w
omen
40
-70
year
s M
= 5
5 ye
ars
Patie
nts
wer
e sm
oker
s,
hype
rten
sive
, or
ov
erw
eigh
t
Prim
ary
care
(U
nite
d St
ates
) T
TM
PET
sca
n ce
nter
(U
nite
d St
ates
) P/
OM
I
Gen
eral
pra
ctic
e (U
nite
d K
ingd
om)
NR
Gen
eral
pra
ctic
e (N
ew Z
eala
nd)
NR
Com
mun
ity h
ealth
ce
nter
s (U
nite
d K
ingd
om)
NR
C: U
sual
car
e: a
dvis
ed a
ccor
ding
to
curr
ent
prac
tice
stan
dard
s 1,:
Sta
ge-b
ased
writ
ten
mat
eria
ls a
nd
verb
al a
dvic
e; 1
,: St
age-
base
d w
ritte
n m
ater
ials
onl
y; I,
: N
on-s
tage
d ve
rbal
ad
vice
I,:
Edu
catio
nal s
trate
gies
, inc
ludi
ng
verb
al a
nd w
ritte
n in
form
atio
n I,:
I, +
beh
avio
ral
stra
tegi
es a
nd
tele
phon
e FU
C:
Info
rmat
ion
on l
ocal
fac
ilitie
s, P
A,
and
heal
th s
ent
I: In
vita
tion
lette
r fr
om p
ract
ition
er t
o at
tend
an
exer
cise
con
sulta
tion
at a
loc
al
faci
lity
and
10-w
eek
exer
cise
pro
gram
se
nt
I,: V
erba
l PA
adv
ice
by g
ener
al
prac
titio
ner
I,: I,
+ w
ritte
n PA
pre
scrip
tion
C:
Leaf
lets
on
prev
entin
g C
VD
I:
C +
exer
cise
refe
rral
+ o
ffer
ed 2
0 ha
lf-pr
ice
exer
cise
ses
sion
s ov
er a
10
-wee
k pe
riod
at l
eisu
re c
ente
r
2 an
d 6
mon
ths
2, 4
, 6,
and
12
wee
ks
8 m
onth
s
6 w
eeks
8, 1
6, 2
6,
Stag
e of
cha
nge,
in
tens
ity-w
eigh
ted
min
utes
/wee
k
Freq
uenc
y an
d du
ratio
n of
m
oder
ate
to
vigo
rous
PA
Epis
odes
of
mod
erat
e an
d vi
goro
us e
xerc
ise
Wal
king
, sp
orts
, an
d ot
her
leis
ure-
tim
e PA
Mod
erat
e an
d an
d 37
wee
ks
vigo
rous
PA
, kc
al k
g 'd
ay-',
SB
P, D
BP, B
MI
Diff
eren
ces
betw
een
grou
ps
at 2
and
6 m
onth
s FU
wer
e N
S. A
ll pa
tient
s, o
n av
erag
e, p
rogr
esse
d to
a
high
er s
tage
at 2
and
6
mon
ths
FU (
P ~
0.0
5)
Bot
h gr
oups
inc
reas
ed
freq
uenc
y (P
<0.
05),
but
1, in
crea
sed
mor
e th
an I
, (P
<0.
05)
at 6
wee
ks,
but
not
at 1
2 w
eeks
. Bot
h gr
oups
inc
reas
ed d
urat
ion
(P <
O.OO
l),
but
diff
eren
ces
betw
een
grou
ps w
ere
NS
1 ve
rsus
C p
atie
nts
repo
rted
mor
e m
oder
ate
(5.0
9 ve
rsus
3.6
4) a
nd
tota
l ep
isod
es (
5.95
ver
sus
4.43
) of
PA
at 8
mon
ths
FU (
P <
0.05
). D
iffer
ence
s be
twee
n gr
oups
for
vig
orou
s ac
tivity
wer
e N
S Pa
rtic
ipat
ion
in a
ny P
A in
crea
sed
to a
gre
ater
ex
tent
in
I, (5
1% to
86%
) th
an i
n I,
(56
% to
77%
) (P
<0.
01).
Mor
e 1,
(73%
) th
an I
, (63
%)
incr
ease
d PA
(P
= 0
.02)
. D
urat
ion
incr
ease
d in
bot
h gr
oups
, bu
t di
ffer
ence
s be
twee
n gr
oups
wer
e N
S M
ore
mod
erat
e m
inut
ed
wee
k at
8 w
eeks
in I
tha
n C
(24
7 ve
rsus
145
, P
~0.
05).
but
not
othe
r tim
es.
Mor
e vi
goro
us
min
utes
/wee
k at
8 w
eeks
in
I th
an C
(49
ver
sus
21,
P =
0.0
6) a
nd 1
6 w
eeks
(5
9 ve
rsus
21,
P <
0.05
), bu
t no
t ot
her
times
. I
expe
nded
mor
e en
ergy
th
an C
pat
ient
s at
8 w
eeks
(3
5 ve
rsus
34,
P <
0.01
) bu
t no
t at
oth
er t
imes
. N
o gr
oup
diff
eren
ces
in S
BP,
DBP
, or
BM
I
Insu
ffic
ient
dat
a to
co
mpu
te r
r no
t co
mpu
ted-
stud
y co
mpa
red
two
inte
rven
- tio
ns
Insu
ffic
ient
dat
a to
co
mpu
te r
r no
t co
mpu
ted-
stud
y co
mpa
red
two
inte
rven
- ti
ons
8-w
eek-
aver
age
PA =
0.2
7 16
-wee
k-av
erag
e PA
= 0
.21
26/3
7-w
eek-
aver
age
PA =
0.03
16
-wee
k-SB
P =
0.0
1 26
/37-
wee
k-SB
P =
0.0
4 16
-wee
k-D
BP
= -
0.01
26
/37-
wee
k-D
BP
= 0
.04
16-w
eek-
BM
I =
0.0
8 26
/37-
wee
k-B
MI
= 0
.06
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Set
tings
(con
tinue
d)
Die
t Int
erve
ntio
ns
%dY
Sa
mpl
e T
heom
In
terv
entio
n D
esig
n &
Se
ttin
g &
D
epen
dent
FO
UO
W-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
A
mm
erm
an e
t al
.”
QE
n-
= 13
8 10
0% m
inor
ity
Bar
on e
t aL
J6
Ber
esfo
rd e
t al
.”
Ber
esfo
rd e
t al
.’%
Cag
giul
a et
aI.l
9
RC
T
n =
368
49
% w
omen
25
-60
year
s M =
42
year
s
RC
T
n =
242
33
% m
inor
ity
218
year
s M =
43
year
s
RC
T
n =
212
1 68
% w
omen
8%
min
ority
RC
T
n =
930
60
% w
omen
19
% m
inor
ity
M =
54
year
s Pa
tient
s ha
d hi
gh
chol
este
rol
Gen
eral
pra
ctic
e C
: U
sual
car
e 8
mon
ths
Dis
cuss
ion
of
Patie
nts
disc
usse
d di
etar
y N
o C
VD
eff
ect
size
s to
be
(Uni
ted
Stat
es)
I: D
ieta
ry r
isk
asse
ssm
ent,
diet
ary
issu
es,
issu
es m
ore
ofte
n w
ith
com
Dut
ed
SCT
Gen
eral
pra
ctic
e (U
nite
d K
ingd
om)
NR
Prim
ary
care
(U
nite
d St
ates
) N
R
Prim
ary
care
(U
nite
d St
ates
) T
TM
Prim
ary
care
(U
nite
d St
ates
) N
R
cultu
rally
spe
cific
nut
ritio
n ed
ucat
ion
mat
eria
ls, a
nd p
hysi
cian
cou
nsel
ing
C: N
o di
etar
y ad
vice
I:
Giv
en n
urse
ins
truct
ion
rega
rdin
g op
timal
bod
y w
eigh
t, di
etar
y ad
vice
, and
bo
okle
t on
basi
cs o
f di
et, r
ecip
es, a
nd
loca
l re
stau
rant
s
12 m
onth
s
C: U
sual
car
e 3
mon
ths
I: Se
lf-he
lp m
ater
ials
and
boo
ster
cal
l by
nu
rse
10 d
ays
late
r
C:
Usu
al c
are
1: Se
lf-he
lp b
ookl
et,
doct
or
mon
ths
endo
rsem
ent,
2-w
eek
rem
inde
r le
tter
from
doc
tor
3 an
d 12
C: U
sual
car
e N
R I,:
Phy
sici
ans
train
ing
in d
ieta
ry
coun
selin
g an
d hy
perc
hole
ster
olem
ia
I,: Ph
ysic
ians
ide
ntifi
ed p
atie
nts
with
hi
gh s
erum
cho
lest
erol
and
ref
erre
d th
em
to n
utri
tion
cent
er f
or t
reat
men
t
know
ledg
e do
ctor
and
rep
orte
d gr
eate
r un
ders
tand
ing
of w
hat
doct
or to
ld t
hem
Fi
ber:
perc
eive
d Fo
r w
omen
: At
3 m
onth
s,
effo
rt a
t in
crea
sing
70
% o
f I
vers
us 2
% o
f C
fib
er a
nd
wer
e tr
ying
to i
ncre
ase
decr
easi
ng f
at;
fiber
; 80%
of I
vers
us 1
%
tota
l, LD
L, a
nd
of C
wer
e try
ing
to
HD
L ch
oles
tero
l de
crea
se f
at. A
t 12
m
onth
s, 4
2% o
f I
vers
us
3% o
f C
wer
e try
ing
to
incr
ease
fib
er;
38%
of
1 ve
rsus
0%
of
C w
ere
tryin
g to
dec
reas
e fa
t. G
ram
s of
fib
er in
crea
sed
for
I bu
t no
t C
at
3 m
onth
s (5
.9 v
ersu
s -0
.7 g
) an
d 12
mon
ths
(2.5
ver
sus
-1.0
g).
No
betw
een-
grou
p di
ffer
ence
s fo
r to
tal,
LDL,
or
HD
L ch
oles
tero
l at
3 o
r 12
m
onth
s D
aily
fat
int
ake
and
ener
gy d
ecre
ased
bet
wee
n ba
selin
e an
d FU
in
both
gr
oups
. Dai
ly f
iber
int
ake
decr
ease
d in
C, w
here
as
fiber
inta
ke i
ncre
ased
in I
B
oth
grou
ps a
t 3-
and
12
-mon
th F
U d
ecre
ased
fa
t in
take
and
inc
reas
ed
fiber
int
ake;
I s
how
ed
grea
ter
decr
ease
in
fat
inta
ke a
nd i
ncre
ase
in f
iber
in
take
Fat
and
fiber
Fat
and
fiber
Tota
l se
rum
In
pat
ient
s w
ho w
ere
not
chol
este
rol
taki
ng l
ipid
-low
erin
g m
eds,
sign
ific
ant m
ean
decr
ease
in
ser
um c
hole
ster
ol l
evel
s fr
om b
asel
ine
to F
U w
ere
seen
in
both
I,
(0.3
1 m
mol
/L o
r 4.
6%)
and
I, (0
.54
mm
ol/L
or
7.7%
), P
<0.
05
For
wom
en:
3-m
onth
-ave
rage
die
tary
ch
ange
atte
mpt
s =
0.7
6 6-
mon
th-a
vera
ge d
ieta
ry
chan
ge a
ttem
pts
= 0
.48
3-m
onth
-fib
er =
0.4
5 6-
mon
th-f
iber
= 0
.26
3-m
onth
-tot
al c
hole
ster
ol
= -
0.04
6-
mon
th-t
otal
cho
lest
erol
=
-0.
03
3-m
onth
-LD
L c
hole
ster
ol
= 0
.02
6-m
onth
-LD
L c
hole
ster
ol
= -
0.02
3-
mon
th-H
DL
cho
lest
erol
=
-0.
05
6-m
onth
-HD
L c
hole
ster
ol
= -
0.01
fa
t =
0.1
0 fib
er =
0.0
8
3 m
onth
s, a
vera
ge f
at =
0.
07
12 m
onth
s, a
vera
ge f
at =
0.1
1 3
mon
ths,
ave
rage
fib
er =
0.01
12
mon
ths,
ave
rage
fib
er =
0.04
I,
vers
us C
= 0
.20
1, v
ersu
s C
= 0
.09
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Set
tings
(con
tinue
d)
Die
t Int
erve
ntio
ns
*dY
Sam
ple
Theo
ry
Inte
rven
tion
Follo
w-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
D
esig
n &
Se
ttin
g &
D
epen
dent
Cam
pbel
l et
aL40
R
CT
n
= 5
58
75%
wom
en
19%
min
ority
M
= 4
0.8
year
s
Coh
en e
t al
." R
CT
n
= 3
0 73
% w
omen
20
-75
year
s M
= 5
9.5
year
s Pa
tient
s w
ere
hype
rten
sive
and
ob
ese
Fam
ily p
ract
ices
(r
ural
and
urb
an)
(Uni
ted
Stat
es)
TT
M,
HB
M
Fam
ily p
ract
ice
(Uni
ted
Stat
es)
BM
C:
No
inte
rven
tion
4 m
onth
s I .
Sent
nut
ritio
n in
form
atio
n pa
cket
&
lore
d to
TTM
, die
tary
int
ake,
and
ps
ycho
soci
al i
nfor
mat
ion
I,: Se
nt s
tand
ard
risk
info
rmat
ion
and
diet
ary
reco
mm
enda
tions
C
: Usu
al c
are
6and
12
I: R
esid
ent t
rain
ing
in w
eigh
t re
duct
ion
and
nutri
tion
educ
atio
n (e
.g.,
low
erin
g ca
lori
e in
take
). Pa
tient
s co
nsul
tatio
n an
d m
onth
ly v
isits
mon
ths
Evan
s et
a]."
, R
CT
C
omm
unity
and
C
: Usu
al c
are
n =
254
un
iver
sity
med
ical
1,
: R
esid
ent p
hysi
cian
tra
inin
g 68
% w
omen
ce
nter
s (U
nite
d 1,:
Res
iden
t phy
sici
ans
wer
e pr
ompt
ed
43%
min
ority
St
ates
) N
R
with
a f
inge
rstic
k se
rum
cho
lest
erol
20
-79
year
s de
term
inat
ion
prio
r to
pat
ient
's cl
inic
Pa
tient
s ha
d hi
gh
visi
t ch
oles
tero
l I,:
I, -+
I,
Gla
sgow
et a
l!, R
CT
Pr
imar
y ca
re
C:
Usu
al c
are
n =
206
(U
nite
d St
ates
) NR
1:
Pers
onal
ized
cou
nsel
ing,
sel
f-he
lp
61%
wom
en
240
year
s M
= 6
2 ye
ars
Patie
nts
wer
e di
abet
ic
repe
ated
mat
eria
ls to
pro
duce
ind
ivid
ualiz
ed g
oal
setti
ng,
and
vide
o ad
dres
sing
bar
riers
. Te
leph
one
FU a
t 1
and
3 w
eeks
. Thr
ee-
mon
th F
U i
nter
vent
ion
sequ
ence
10 m
onth
s
12 m
onth
s
Hym
an e
t al
.44
RC
T
n =
123
75
% w
omen
80
% m
inor
ity
18-6
5 ye
ars
M =
56.
7 ye
ars
Publ
ic c
omm
unity
C
: U
sual
car
e (b
rief
phys
icia
n co
unse
ling)
6 m
onth
s he
alth
cen
ters
(U
nite
d St
ates
) SC
T ph
one
calls
, fou
r I-
hour
cla
sses
I:
Die
t as
sess
men
t, co
mpu
ter-
inte
ract
ive
Fat
Wei
ght
Die
tary
cha
nge
atte
mpt
s, t
otal
se
rum
cho
lest
erol
Fat,
BM
I, to
tal
seru
m c
hole
ster
ol
Fat,
wei
ght,
tota
l se
rum
cho
lest
erol
Tota
l fa
t de
crea
sed
by
23%
in I
, ver
sus
9% in
I,,
and
3% in
C (
P <
O.IO
). Sa
tura
ted
fat d
ecre
ased
by
26%
in I
,, 11
% i
n I,,
and
3% in
C (
P <
0.05
) Fr
om b
asel
ine
to 6
m
onth
s, w
eigh
t de
crea
sed
in I
but
inc
reas
ed in
C
(-1.8
ve
rsus
0.5
6 kg
, P
< .0
04).
From
6 t
o 12
m
onth
s, w
eigh
t in
crea
sed
in b
oth
grou
ps (
0.94
ver
sus
0.73
kg,
P >
0.10
). Fr
om
base
line
to 1
2 m
onth
s,
wei
ght
decr
ease
d in
I bu
t in
crea
sed
in C
(-0
.88
vers
us 1
.3 k
g, P
= 0
.10)
Pa
tient
s of
I, a
nd I
, re
side
nts
had
grea
ter
know
ledg
e of
thei
r el
evat
ed c
hole
ster
ol l
evel
s th
an I
, or
C r
esid
ents
, and
w
ere
mor
e lik
ely
to r
epor
t tr
ying
to
chan
ge t
heir
die
t (P
= 0
.005
). D
ecre
ases
in
seru
m c
hole
ster
ol d
id n
ot
diff
er b
y gr
oup
Kca
l/day
dec
reas
ed f
rom
17
40 to
154
7 in
I,
1761
to
165
9 in
C, P
<0.
05.
Perc
ent
fat
decr
ease
d fr
om
33.8
to
30.5
in
1, 32
.9 t
o 32
.0 i
n C
, P <
0.03
. Pe
rcen
t sa
tura
ted
fat
decr
ease
d fr
om 1
1.2
to
9.7
in I
, 10
.8 to
10.
7 in
C,
P <0.005. Se
rum
ch
oles
tero
l de
crea
sed
from
21
7 to
208
in
I, 22
3 to
22
6 in
C, P
<0.
005.
BM
I di
d no
t ch
ange
in I
or
C
Seru
m c
hole
ster
ol
decr
ease
d in
I f
rom
273
.2
mg/
dL t
o 26
5.0
mg/
dL
(P =
0.0
5).
For
C, s
erum
ch
oles
tero
l de
crea
sed
from
27
2.1
mg/
dL t
o 26
7.6
mg/
dL (
P =
0.3
2).
Fat
scor
e an
d w
eigh
t dec
reas
es
betw
een
grou
ps w
ere
NS
1, v
ersu
s C
, fat
= 0
.16
I, ve
rsus
C, f
at =
0.0
4 1,
ver
sus
C,
satu
rate
d fa
t =
0.1
8 I,
vers
us C
, sa
tura
ted
fat
= 0
.05
6 m
onth
s =
0.3
7 12
mon
ths
= 0
.29
Die
tary
cha
nge
atte
mpt
s =
0.18
ch
oles
tero
l =
0.0
5
Die
tary
ene
rgy
= 0
.14
aver
age
fat
= 0
.20
BMI
= 0
.03
chol
este
rol
= 0
.22
Cho
lest
erol
= 0
.04
fat
= 0
.01
wei
ght
= 0
.01
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Setti
ngs
(con
tinue
d)
Die
t Int
erve
ntio
ns
sr
Des
ign
&
Sett
ing
&
Dep
ende
nt
Stud
v Sa
mpl
e Th
eow
In
terv
entio
n FO
UO
W-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
Ja
ck e
t Q
E
Fam
ily m
edic
ine
I: R
esid
ents
trai
ning
in
seru
m f
inge
rstic
k B
asel
ine
n =
483
6 (U
nite
d St
ates
) NR
ch
oles
tero
l sc
reen
ing,
die
t as
sess
men
t, ve
rsus
1 y
ear
76%
wom
en
20-6
5 ye
ars
M =
33
year
s
and
coun
selin
g, a
nd F
U p
roto
col
Key
serli
ng e
t a]
." R
CT
Lo
w-i
ncom
e C
: Usu
al c
are
4, 7
, and
12
n =
372
co
mm
unity
and
I:
Die
tary
ris
k as
sess
men
t, cl
inic
ian
mon
ths
5 1%
m
inor
ity
67%
wom
en
rura
l he
alth
cen
ters
cou
nsel
ing,
and
cul
tura
lly s
peci
fic p
atie
nt
(Uni
ted
Stat
es)
NR
ed
ucat
ion
mat
eria
ls.
Ref
erra
ls t
o di
etiti
an
M =
56
year
s Pa
tient
s ha
d hi
gh
chol
este
rol
and
low
in
com
e
or h
ealth
edu
cato
r or
pro
mpt
for
dru
g th
erap
y if
chol
este
rol
rem
aine
d el
evat
ed
Ock
ene
et
RC
T
Inte
rnal
med
icin
e C
: Usu
al c
are
n =
116
2 (U
nite
d St
ates
) I,
: Ph
ysic
ian
nutr
ition
cou
nsel
ing
66%
wom
en
Patie
nt-c
ente
red
trai
ning
20
-65
year
s I,:
Phy
sici
an n
utrit
ion
coun
selin
g M
= 4
9.3
year
s tra
inin
g pl
us o
ffic
e su
ppor
t Pa
tient
s w
ere
dysl
ipid
emic
12 m
onth
s
Tota
l se
rum
ch
oles
tero
l
Die
tary
Ris
k A
sses
smen
t, to
tal
and
HD
L se
rum
ch
oles
tero
l
Fat;
wei
ght;
tota
l, LD
L, a
nd H
DL
chol
este
rol
The
per
cent
of
patie
nts
scre
ened
inc
reas
ed f
rom
Mea
n ch
oles
tero
l de
crea
sed
from
5.3
6 to
5.0
8 m
mol
/L
(P =
0.0
03)
Patie
nts
not
taki
ng l
ipid
- lo
wer
ing
med
icat
ion:
se
rum
cho
lest
erol
de
crea
sed
mor
e in
I t
han
C a
t 4
mon
ths
(-0.2
8 ve
rsus
-0.
14
mm
ol/L
, P
<0.
05),
and
7 m
onth
s (-
0.27
ve
rsus
-0.
09
mm
ol/L
, P
C0.
05).
but
not
12 m
onth
s. L
DL
chol
este
rol
decr
ease
d m
ore
in 1
than
C a
t 7
mon
ths
(-0.
26
vers
us -
0.09
m
mol
/L,
P <
0.05
), bu
t di
ffer
ence
s at
4 a
nd 1
2 m
onth
s w
ere
NS.
Die
tary
sc
ores
impr
oved
mor
e in
I
than
C p
atie
nts
at 4
m
onth
s (-5
.5
vers
us -
1.9,
P
<0.
05)
and
12 m
onth
s (-
5.4
vers
us -
2.2,
P
<0.
05)
Com
pare
d w
ith C
, I,
decr
ease
d fa
t 1.
6%.
(P <
0.01
), de
crea
sed
wei
ght
2.3
kg (P <
0.00
1),
and
decr
ease
d LD
L ch
oles
tero
l 0.
10 m
mol
lL
(3.8
mg/
dL)
mor
e
16%
to 2
3% (
P <
0.05
).
Tota
l ch
oles
tero
l =
0.1
0
4-m
onth
-tot
al c
hole
ster
ol
= 0
.11
7-m
onth
-tot
al c
hole
ster
ol
= 0
.14
12-m
onth
-tot
al c
hole
ster
ol
= 0
.07
4-m
onth
-LD
L ch
oles
tero
l =
0.0
9 7-
mon
th-L
DL
chol
este
rol
= 0
.14
12-m
onth
-LD
L ch
oles
tero
l =
0.1
0 4-
mon
th-d
iet
= 0
.24
12-m
onth
-die
t =
0.2
2
I, v
ersu
s C
ave
rage
fa
t =
0.0
3 I,
vers
us C
ave
rage
fa
t =
0.1
0 I,
vers
us C
wei
ght
= 0
.03
I, ve
rsus
C w
eigh
t = 0
.07
I, ve
rsus
C c
hole
ster
ol =
-0.0
2 I,
vers
us C
cho
lest
erol
=
0.10
1,
vers
us C
LD
L =
-0.0
2 1,
vers
us C
LD
L =
0.0
8 I,
vers
us C
HD
L =
0.0
5 I,
vers
us C
HD
L =
0.0
5
2
P
$ a
Die
t Int
erve
ntio
ns
2 St
udy
Sam
ple
The
ory
Inte
rven
tion
Follo
w-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
2
Rho
des
et a
1.4n
RC
T
Out
patie
nt c
linic
s C
: U
sual
car
e (1
0-m
inut
e di
etar
y 3
mon
ths
Die
tary
ene
rgy;
BM
I de
crea
sed
grea
ter
in 1
, B
MI
= 0
.31
v,
n =
100
(U
nite
d St
ates
) N
R in
stru
ctio
n ba
sed
on N
CEP
die
t she
et)
fat;
tota
l, LD
L,
vers
us C
(1.
1 ve
rsus
0.6
), kc
al =
0.1
9
6 > 6%
min
ority
I,:
Com
preh
ensi
ve c
onsu
ltatio
n w
ith
chol
este
rol
decr
ease
d di
etar
y en
ergy
, ch
oles
tero
l =
0.1
5
Tabl
e 1.
Sum
mar
y of P
hysi
cal A
ctiv
ity, D
iet,
and
Com
bine
d In
terv
entio
ns C
ondu
cted
in H
ealth
Car
e S
ettin
gs (c
ontin
ued)
- $
Des
ign
&
Sett
ing
&
Dep
ende
nt
51%
wom
en
OR
usua
l ca
re +
gro
cery
sho
ppin
g gu
ide
and
HD
L P
<0.0
01.
Bot
h gr
oups
fa
t =
0.3
3
30-6
5 ye
ars
diet
itian
OR
com
preh
ensi
ve c
onsu
ltatio
n bu
t gr
oup
diff
eren
ces
wer
e LD
L =
0.1
0 M
= 4
7.6
year
s H
DL
= 0
.09
cn
with
die
titia
n an
d tw
o ad
ded
cons
ulta
tions
N
S (4
19 v
ersu
s 34
3 fo
r I,
2
Patie
nts
had
high
ve
rsus
C).
Perc
ent
fat
P ch
oles
tero
l de
crea
sed
grea
ter
in I,
u
vers
us C
pat
ient
s (9
ver
sus
6).
P <
0.00
1. B
oth
grou
ps
decr
ease
d to
tal
seru
m
chol
este
rol
(1 0
% v
ersu
s 7%
dec
reas
e fo
r I,
vers
us
C)
and
LDL
chol
este
rol
(1 1
% v
ersu
s 9%
dec
reas
e fo
r I,
vers
us C
), bu
t gr
oup
diff
eren
ces
wer
e N
S
Com
bine
d In
terv
entio
ns
Cup
ples
&
RC
T
Gen
eral
pra
ctic
e C
: N
o he
alth
edu
catio
n 24
mon
ths
Epis
odes
of
At
FU,
mor
e I
(44%
) th
an
Ave
rage
PA
= 0
.23
M~
Kn
igh
t~~
n
= 6
88
(Ire
land
) N
R
I: Pa
tient
s gi
ven
advi
ce r
egar
ding
CV
D
PA/w
eek,
fib
er,
C (
24%
) ex
erci
sed
7+
fiber
= 0
10
26%
wom
en
risk
fact
ors.
Pat
ient
s re
view
ed a
nd g
iven
sa
tura
ted
fat,
SBP,
tim
eslw
eek,
P <
0.00
01,
satu
rate
d fa
t =
0.1
0 38
-74
year
s he
alth
edu
catio
n at
fou
r m
onth
ly
DBP
, se
rum
an
d in
crea
sed
exer
cise
in
suff
icie
nt d
ata
to
M =
63.
1 ye
ars
inte
rvie
ws
chol
este
rol,
BM
I (3
4% v
ersu
s 21
%),
com
pute
r f
or S
BP,
DBP
, Pa
tient
s ha
d an
gina
P
<O.O
OOl.
Die
t im
prov
ed
chol
este
rol,
and
BM
I m
ore
in I
tha
n C
. D
iffer
ence
s be
twee
n gr
oups
w
ere
NS
for
SBP,
DBP
, ch
oles
tero
l, an
d B
MI
Cup
ples
&
RC
T
Gen
eral
pra
ctic
e C
: N
o he
alth
edu
catio
n 24
and
60
Epis
odes
of
Epis
odes
of
PA i
ncre
ased
PA
, 2
year
= 0
.20
McK
nigh
tS0
n =
688
(I
rela
nd)
NR
I:
Patie
nts
give
n ad
vice
reg
ardi
ng C
VD
m
onth
s PA
/wee
k, d
iet
from
bas
elin
e to
2-y
ear
FU
PA,
5 ye
ar =
0.0
5 26
% w
omen
fo
r I
(3.6
to
4.0)
mor
e di
et, 2
yea
r =
0.1
9 38
-74
year
s th
an C
pat
ient
s (3
.8 t
o 3.
2).
diet
, 5 y
ear
= 0
.05
M =
63.
1 ye
ars
inte
rvie
ws
chol
este
rol,
BM
I P
<O.O
OI.
Die
t im
prov
ed
SBP,
2 y
ear
= 4.0
5 Pa
tient
s ha
d an
gina
fr
om b
asel
ine
to 2
-yea
r FU
SB
P, 5
yea
r =
0.0
2 m
ore
in I
(21
.1 t
o 23
.7)
DBP
, 2
year
= 4
.02
th
an C
(21
.1 t
o 22
.1),
but
DBP
, 5
year
= 0
.05
diff
eren
ces
wer
e N
S at
ch
oles
tero
l, 2
year
= -
0.04
5-
year
FU
. G
roup
ch
oles
tero
l, 5
year
= -
0.03
di
ffer
ence
s in
cha
nges
B
MI,
2 ye
ar =
-0.
03
from
bas
elin
e to
2-
and
BM
I, 5
year
= -
0.02
5-
year
FU
for
SB
P, D
BP,
chol
este
rol,
and
BM
I w
ere
NS
risk
fact
ors.
Patie
nts
wer
e re
view
ed a
nd
give
n he
alth
edu
catio
n at
fou
r m
onth
ly
com
posi
te,
SBP,
D
BP,
seru
m
YY 0
ul
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Set
tings
(con
tinue
d)
Com
bine
d In
terv
entio
ns
stud
y Sa
mpl
e T
heor
y In
terv
entio
n Fo
llow
-UP
Var
iabl
es
Res
u Its
Des
ign
&
Sett
ing &
D
epen
dent
E
ffec
t Siz
e r
Dow
ell
et a
Ls'
Fam
ily H
eart
St
udy
Gro
ups2
Impe
rial
Can
cer
Res
earc
h Fu
nd
OX
CH
ECK
Stu
dy
Gro
ups3
Impe
rial
Can
cer
Res
earc
h Fu
nd
OX
CH
ECK
Stu
dy
Gro
ups4
QE
n
= 5
624
28-6
7 ye
ars
RC
T
n =
12
,472
40
% w
omen
35
-61
year
s M
(w
omen
) =
49
year
s M
(m
en)
= 5
1.5
year
s
RC
T
n =
612
4 56
% w
omen
35
-64
year
s M
= 4
9 ye
ars
RC
T
n =
412
1 55
% w
omen
35
-64
year
s M
= 4
9 ye
ars
Gen
eral
pra
ctic
e (U
nite
d K
ingd
om)
NR
Gen
eral
pra
ctic
e (U
nite
d St
ates
) N
R
Gen
eral
pra
ctic
e (U
nite
d K
ingd
om)
NR
Gen
eral
pra
ctic
e (U
nite
d K
ingd
om)
NR
C:
No
heal
th c
heck
I,:
Hea
lth c
heck
in
year
1
I,:
Hea
lth c
heck
in
year
2
I,: H
ealth
che
cks
in y
ears
1 a
nd 2
C:
Scre
ened
at
I-ye
ar F
U
1: A
sses
smen
t an
d fe
edba
ck r
egar
ding
C
VD
ris
k; b
ookl
et t
o do
cum
ent
lifes
tyle
ch
ange
s, a
nd p
amph
lets
. H
igh-
risk
pa
tient
s in
vite
d fo
r FU
(1
tim
ehon
th,
3 m
onth
s)
C:
Sche
dule
d fo
r a
heal
th c
heck
1:
Nur
se p
rovi
ded
a he
alth
che
ck a
nd
coun
sele
d pa
tient
s ab
out
CV
D r
isk
fact
ors
(M =
44-
min
ute
visi
t)
C:
Sche
dule
d fo
r a
heal
th c
heck
I:
Nur
se p
rovi
ded
a he
alth
che
ck a
nd
coun
sele
d pa
tient
s ab
out
CV
D r
isk
fact
ors
(M =
44-
min
ute
visi
t)
12 a
nd 2
4 V
igor
ous
exer
cise
, m
onth
s di
et s
core
, wei
ght
12 m
onth
s Se
rum
cho
lest
erol
, SB
P, D
BP,
wei
ght
12 m
onth
s V
igor
ous
exer
cise
<I
tim
ehon
th,
diet
, se
rum
ch
oles
tero
l, SB
P,
DB
P, B
MI
36 m
onth
s V
igor
ous
exer
cise
<I
tim
ehon
th,
diet
, se
rum
ch
oles
tero
l, SB
P,
DBP
, B
MI
Dif
fere
nces
wer
e N
S fo
r in
crea
sed
vigo
rous
exe
rcis
e or
die
t. M
ore
I, lo
st 2
7 Ib
s (1
8%)
than
C (
ll%
), I
, (l
o%),
or
I, (1
4%),
P
= 0
.01.
Mea
n w
eigh
t lo
ss
betw
een
grou
ps w
as N
S Fo
r w
omen
: I
mad
e gr
eate
r im
prov
emen
ts t
han
C a
t 12
-mon
th F
U:
decr
ease
d to
tal
chol
este
rol
(5.6
1 ve
rsus
5.4
8 m
mol
lL),
SBP
(131
ver
sus
123
mm
Hg)
, D
BP
(81
vers
us 7
9 m
m
Hg)
, an
d w
eigh
t (6
6.83
ve
rsus
66.
06 k
g)
For
wom
en:
Few
er I
rep
orte
d <1
ex
erci
se s
essi
onho
nth
than
C (
65.8
% v
ersu
s 69
.4%
), P
<0.0
5. F
ewer
I
dran
k fu
ll-cr
eam
milk
or
used
but
terh
ard
mar
gari
ne
than
C,
P <0
.05.
C
hole
ster
ol w
as l
ower
in
I th
an C
(6.
00 v
ersu
s 6.
20),
P <0
.05.
SB
P w
as lo
wer
in
I th
an i
n C
(12
2.3
vers
us
125.
7), P
C0.
05.
DB
P w
as
low
er i
n I
than
C (
73.2
ve
rsus
74.
9),
P C
0.05
. B
MI
diff
eren
ces
betw
een
grou
ps
wer
e N
S Fo
r w
omen
: D
iffe
renc
es b
etw
een
grou
ps
for
exer
cise
ses
sion
s/
mon
th w
ere
NS.
Few
er I
used
ful
l-cr
eam
milk
(2
0.1%
) th
an C
(26
.7%
),
P <0
.05,
and
few
er u
sed
butte
r or
har
d m
arga
rine
(2
0.7%
ver
sus
29.2
%.
P <0
.05)
. To
tal
chol
este
rol
was
low
er i
n I
than
C (
5.98
ve
rsus
6.2
6).
P <0
.05.
SB
P lo
wer
in I
tha
n C
(12
4.7
vers
us 1
27.0
), P
10.0
5.
DB
P lo
wer
in
1 th
an C
(7
4.3
vers
us 7
6.0,
WO
.05)
. B
MI
diff
eren
ces
betw
een
grou
ps w
ere
NS
Vig
orou
s ex
erci
se =
0.0
1 di
et =
0.0
2 w
eigh
t lo
ss =
0.0
3
For
wom
en:
chol
este
rol
= 0
.02
SBP
= 0
.09
DB
P= 0
.05
wei
ght
= 0
.04
For
wom
en:
vigo
rous
exe
rcis
e =
0.0
4 av
erag
e of
but
ter
and
full-
cr
eam
milk
= 0
.1 1
chol
este
rol
= 0
.07
SBP
= 0
.08
DB
P =
0.0
7 B
MI
= 0
.02
For
wom
en:
vigo
rous
exe
rcis
e =
0.0
2 av
erag
e of
but
ter
and
full-
cr
eam
milk
= 0
.09
chol
este
rol
= 0
.1 1
SBP
= 0
.06
DB
P =
0.0
7 B
MI
= 0
.03
2 s 3 ’.
Com
bine
d In
terv
entio
ns
3
Des
ign
&
Sett
ing
&
Dep
ende
nt
b
(D
Stud
y s
Tabl
e 1.
Sum
mar
y of
Phy
sica
l Act
ivity
, Die
t, an
d C
ombi
ned
Inte
rven
tions
Con
duct
ed in
Hea
lth C
are
Set
tings
(con
tinue
d)
Sam
ple
The
ory
Inte
rven
tion
Follo
w-U
P V
aria
bles
R
esul
ts
Eff
ect S
ize r
‘. 2:
Kel
lyss
a s cn p 2
Lind
holm
et
al.s6
?
u
Logs
don
et a
l.”
Ros
amon
d et
aLS
8 W
ISE
WO
MA
N
wor
king
gro
upS9
RC
T
n =
264
70
% w
omen
3%
min
ority
18
-60
year
s
RC
T
n =
681
15
% w
omen
30
-59
year
s M
= 4
8 ye
ars
Patie
nts
had
high
ch
oles
tero
l +
two
CV
D r
isk
fact
ors
QE
n
= 2
128
45.3
% w
omen
2.
8% m
inor
ity
21 8
year
s
QE
n
= 19
57
100%
wom
en
41%
min
ority
M
= 6
3 ye
ars
Patie
nts
had
low
in
com
e
Fam
ily p
ract
ice
(Uni
ted
Stat
es)
NR
Hea
lth c
ente
rs
(Sw
eden
) NR
Mul
tispe
cial
ty
prac
tices
(U
nite
d St
ates
) N
R
Nat
ionw
ide
Bre
ast
& C
ervi
cal
Can
cer
Ear
ly D
etec
tion
Prog
ram
site
s (U
nite
d St
ates
) T
TM
, SC
T, B
M
C:
Usu
al c
are
4 w
eeks
I,:
Ris
k as
sess
men
t, ph
ysic
ian
coun
selin
g,
lifes
tyle
pre
scri
ptio
n, a
nd e
duca
tiona
l m
ater
ials
; I,:
Ris
k as
sess
men
t, nu
rse
prov
ided
edu
catio
nal
mat
eria
ls;
I,: R
isk
asse
ssm
ent
only
C
: U
sual
car
e (b
rief
phy
sici
an c
ouns
elin
g 18
mon
ths
for
CV
D r
isk
redu
ctio
n)
1: B
rief
phys
icia
n co
unse
ling,
six
gro
up
sess
ions
led
by
doct
or o
r nu
rse,
vid
eos
C:
Usu
al c
are
12 m
onth
s 1:
Phys
icia
n be
havi
oral
ris
k fa
ctor
sc
reen
ing
and
coun
selin
g
I,: D
eliv
ery
of th
e “N
ew L
eaf‘
6a
nd 1
2 pr
ogra
m i
n th
ree
in-p
erso
n in
terv
entio
n m
onth
s,
coun
selin
g se
ssio
ns. D
iet
and
PA
7 m
onth
s fo
r re
com
men
datio
ns,
goal
set
ting,
PA
and
die
t co
okbo
ok, t
ailo
red
tip s
heet
s, a
nd
nont
ailo
red
tip s
heet
s I,:
Com
preh
ensi
ve h
ealth
his
tory
and
C
VD
ris
k as
sess
men
t. R
efer
rals
and
co
unse
ling
as i
ndic
ated
Beh
avio
r ch
ange
, in
tent
to
chan
ge
Fat,
fibe
r, ex
erci
se,
seru
m c
hole
ster
ol,
BM
I, SB
P, D
BP
Vig
orou
s ex
erci
se
tl
tim
e/w
eek,
w
eigh
t lo
ss
Perc
ent
of p
eopl
e ac
tive,
Die
tary
R
isk
Ass
essm
ent,
BM
I, SB
P, D
BP,
i.e.,
tota
l an
d H
DL
chol
este
rol
Ove
rall,
C h
ad s
igni
fica
ntly
le
ss i
nter
est
in c
hang
ing
and
mad
e si
gnif
ican
tly
few
er c
hang
es th
an 1
. I,
m
ade
mor
e ch
ange
s th
an 1
, an
d I,
patie
nts
(NS)
G
reat
er c
hang
es in
I
com
pare
d w
ith C
. D
iffe
renc
e be
twee
n I
and
C
in d
ecre
asin
g se
rum
ch
oles
tero
l w
as -
0.15
m
mol
/L (
P <0
.05), -
0.10
m
mol
/L f
or L
DL,
-0.
09
for
BM
I, -1
.2
mm
Hg
for
SBP,
and
-0.
10
mm
Hg
for
DB
P O
f th
ose
doin
g no
vig
orou
s ex
erci
se a
t ba
selin
e, 3
1.5%
of
I ve
rsus
24.
1% o
f C
st
arte
d ex
erci
sing
at
FU,
P <
O.IO
. O
f th
ose
over
wei
ght
at b
asel
ine,
36
.6%
of
1 ve
rsus
24.
8%
of C
lost
25
Ibs
at F
U,
P <
0.01
Pe
rcen
t ac
tive
incr
ease
d in
bo
th I
, and
I,
patie
nts
(5.9
% v
ersu
s 9.
3%
incr
ease
, P <
0.05
), bu
t di
ffer
ence
s be
twee
n gr
oups
w
ere
NS.
Die
tary
im
prov
emen
ts s
een
in t
he
I, pa
tient
s on
ly,
P< 0
.05.
To
tal
chol
este
rol,
SBP,
and
D
BP
decr
ease
d in
bot
h gr
oups
at
6 an
d 12
mon
ths,
di
ffer
ence
s be
twee
n gr
oups
w
ere
NS.
BM
I de
crea
sed
at
6 an
d 12
mon
ths
for
1,
Dat
ient
s on
lv (
-0.3
an
d
Ow
ing
to t
he l
ack
of
spec
ific
ity i
n ou
tcom
es, r
no
t co
mpu
ted
Exer
cise
= 0
.00
tota
l ch
oles
tero
l =
0.1
1 LD
L =
0.0
7 H
DL
= 0
.04
BM1
= 0
.03
SBP
= 0
.05
DB
P =
0.0
Vig
orou
s ex
erci
se =
0.0
8 w
eigh
t lo
ss =
0.1
2
PA,
1, A
, 7
mon
ths
= 0
.12
PA,
I, A
, 7
mos
= 0
.19
Die
t, I,
A,
7 m
onth
s =
0.3
1 D
iet,
I, A
, 7
mon
ths
= 0
.00
chol
este
rol,
I, A
, 6
mon
ths
= 0
.21
chol
este
rol,
I, A
, 6
mon
ths
= 0
.12
chol
este
rol,
I, A
, 12
m
onth
s =
0.2
1 ch
oles
tero
l, I,
A,
12
mon
ths
= 0
.18
HD
L, I
, A
, 6
mon
ths
=
-0.
I0
HD
L. I
. A
. 6
mon
ths
=
’1
‘0.2
, P
<0.
65)
-0.0
1
ru 0
u
ru
0
CD
Tabl
e 1.
Sum
mar
y of P
hysi
cal A
ctiv
ity, D
iet,
and
Com
bine
d In
terv
entio
ns C
ondu
cted
in H
ealth
Car
e Se
tting
s (c
ontin
ued)
C
ombi
ned I
nter
vent
ions
D
esig
n &
Se
ttin
g &
D
epen
dent
St
udv
Sam
ple
Theo
rv
Inte
rven
tion
Follo
w-U
D
Var
iabl
es
Res
ults
E
ffec
t Siz
e r
Ros
amon
d et
aLS
* (c
ontin
ued)
Step
toe
et a
L60
RC
T
Gen
eral
pra
ctic
e C
: Usu
al c
are
4 an
d 12
n
= 8
83
(Uni
ted
Kin
gdom
) I:
Beh
avio
ral
coun
selin
g by
nur
ses.
mon
ths
54%
wom
en
TT
M
Patie
nts
wer
e in
vite
d fo
r th
ree
brie
f 46
.7 y
ears
Pa
tient
s ha
d 1+
m
odifi
able
CV
D ri
sk
fact
or
coun
selin
g se
ssio
ns i
f th
ey h
ad t
wo
risk
fact
ors,
and
one
ses
sion
if
they
had
one
ris
k fa
ctor
. Pat
ient
s w
ere
cont
acte
d on
ce o
r tw
ice
by t
elep
hone
to
enco
urag
e be
havi
or c
hang
e
Sess
ions
of
activ
ity R
elat
ive
to b
asel
ine,
in
pas
t 4
wee
ks,
exer
cise
ses
sion
s in
crea
sed
fat,
BM
I, w
eigh
t, at
4 a
nd 1
2 m
onth
s m
ore
seru
m c
hole
ster
ol,
in I
(33
.2%
and
146
%)
SBP,
DB
P th
an C
(13
.5%
and
88.
8%),
P <
0.05
. Fa
t sc
ores
im
prov
ed a
t 4
and
12
mon
ths
mor
e in
I (
26%
an
d 23
.3%
) th
an C
(1
1.5%
an
d 15
.2%
), P
<0.0
5.
Diff
eren
ces
betw
een
grou
ps
wer
e N
S fo
r B
MI,
wei
ght,
SBP,
DBP
, an
d ch
oles
tero
l
HD
L, 1
, A
, 12
mon
ths
=
0.09
H
DL,
1,
A,
12 m
onth
s =
0.09
SB
P, I
, A,
6 m
onth
s =
0.0
4 SB
P, I
, A,
6 m
onth
s =
0.0
7 SB
P, I
, A,
12
mon
ths
=
0.10
SB
P, 1,
A, 1
2 m
onth
s =
0.
13
DBP
, I,
A,
6 m
onth
s =
0.1
1 D
BP,
1, A,
6 m
onth
s =
0.1
3 D
BP,
I, A
, 12
mon
ths
=
0.12
D
BP,
I, A
, 12
mon
ths
=
0.12
B
MI,
I, A
, 6
mon
ths
= 0
.16
BM
I, 1,
A, 6
mon
ths
= 0
.07
BM
I, I,
A,
12 m
onth
s =
0.
12
BM
I, I,
A, 1
2 m
onth
s =
0.
00
PA 4
mon
ths
= 0
.12
PA 1
2 m
onth
s =
0.1
2 fa
t 4
mon
ths
= 0
.12
fat
12 m
onth
s =
0.0
9 B
MI
4 m
onth
s =
0.0
4 B
MI
12 m
onth
s =
0.0
4 SB
P 4
mon
ths
= 0
.08
SBP
12 m
onth
s =
0.0
8 D
BP
4 m
onth
s =
0.0
5 D
BP
12 m
onth
s =
-0.
01
chol
este
rol
12 m
onth
s =
-0
.01
Not
e: P
ositi
ve e
ffec
t siz
es re
fer t
o a
supe
riorit
y of
the
inte
rven
tion g
roup
(s) on
the
varia
ble
of in
tere
st (o
r a p
ositi
ve c
hang
e on
the
varia
ble
of in
tere
st fo
r pre
-pos
t des
igns
). A
bbre
viat
ions
(in
alph
abet
ical
ord
er):
BM
= b
ehav
ior m
odifi
catio
n;
BM
I = b
ody
mas
s in
dex
(kgm
’);
C =
com
paris
on o
r con
trol
gro
up; C
VD
=ca
rdio
vasc
ular
dis
ease
; DB
P =
dia
stol
ic b
lood
pre
ssur
e; F
U =
follo
w-u
p; H
BM
= H
ealth
Bel
ief M
odel
; HD
L =
hig
h-de
nsity
lipo
prot
ein;
HET
= H
ealth
Edu
catio
n Th
eory
; I =
Inte
rven
tion
grou
p; L
DL
= lo
w-d
ensi
ty li
popr
otei
n; M =
mea
n; M
I = m
otiv
atio
nal i
nter
view
ing;
NR
= n
ot re
porte
d; N
S =
not
sig
nific
ant;
PA =
phy
sica
l act
ivity
; PA
SE =
Phy
sica
l Act
ivity
Sca
le fo
r the
Eld
erly
; PlO
MI =
Pro
cess
/ O
utco
me
Mod
el fo
r Int
erve
ntio
n; Q
E =
qua
si-e
xper
imen
tal;
RC
T =
rand
omiz
ed c
linic
al tr
ial;
SBP
= s
ysto
lic b
lood
pre
ssur
e; S
CT
= S
ocia
l Cog
nitiv
e/Le
arni
ng T
heor
y; I
TM
= T
rans
theo
retic
al M
odel
.
tive papers of interventions included in our review, three reported on the same population at different follow-up points, two reported only comparisons between two dif- ferent types of interventions, and one did not distinguish the type of outcome. Thus, correlation coefficients from 32 unique interventions were available for analysis. Eleven studies included PA-only interventions, 13 included diet- only interventions, and eight included combined inter- ventions. From these 32 interventions, 170 correlation coefficients were computed across the CVD risk factors because many studies contributed multiple correlation coefficients for the same CVD risk factor (e.g., different follow-up periods or different comparison groups, etc.). We chose not to report correlation coefficients weighted by sample size, as is common in meta-analyses, because doing so would over-represent these studies in the effect size estimates.
Correlation Coefficients for CVD Risk Factors The mean correlation coefficients by each ofthe CVD risk factors are presented in Table 2. The average effect of treatment was generally small but statistically significant ( P <0.05; 95% confidence interval [CI] does not include 0) for PA or exercise (n = 37), BMI or body weight ( n = 22), dietary fat (n = 21), SBP (n = 14), DBP (n = 14), total serum cholesterol (n = 25), and LDL (n = 9). Correlation coeffi- cients were not statistically significant for PA stage of readiness for change (n = 5) , energy intake (n = 2), general dietary factors (n = 2), dietary fiber (n = 6), dietary stage of readiness for change (n = 3), or HDL (n = 10). Means that were computed from a small number of correlation coeffi- cients should be interpreted cautiously.
Table 2. Mean Effect Sizes (r) for CVD Risk Factors
Moderating Factors (Stratified Analysis) As is customary in the reporting of effect sizes, we also examined whether correlation coefficients for CVD risk factors (PA or exercise, BMI or weight, dietary fat, SBP, and total serum cholesterol) differed when stratified by important moderating variables: participant age (coded as mean age of sample 150 years or >50 years), use of a be- havioral theory to guide the intervention (coded as no stated theory or a stated behavioral theory), type of inter- vention (coded as PA only, diet only, or combined inter- vention), type of comparison group (coded as usual care, brief counseling, or pre-post design), and follow-up pe- riod (coded as <6 months or 26 months). The number of correlation coefficients for each stratum is presented in Table 3. Correlation coefficients for CVD risk factors, strati- fied by moderating factors, are shown in Table 4.
Age. With the exception of SBP, interventions tended to produce larger effects in samples with a mean age of >50 years.
Behavior theory. The most common theories or mod- els were Social Cognitive Theory, the Transtheoretical Model, and behavior modification principles. The use of a behavior theory to guide the intervention did not have a major impact on study effectiveness, although for both BMI and SBP, studies using a behavior theory produced somewhat larger correlation coefficients than studies not reporting the use of a behavior theory. Intervention ef- fects were somewhat larger, however, for dietary fat in studies that did not report the use of a behavior theory.
Type of intervention. Diet-only interventions were somewhat more effective in reducing body weight than PA-only or combined interventions. Combined interven-
CVD Risk Factor n r 95% CI Physical activity
37 0.0983 0.0747-0.1220 5 0.0676 -0.2144-0.3496
Physical activity Stage of change
BMI or weight 22 0.0853 0.0376-0.133 1 Diet
Fat 21 0.121 1 0.085 1 4 . 1 571 Caloric intake 2 0.2350 -0.9968-1 .OO
-0.7668-1 .OO General (not specified) 2 0.1 169 Fiber 6 0.1561 -0.0 1924.33 15 Stage of change 3 0.4705 -0.2514-1.00
Systolic 14 0.0572 0.03 15-0.0829 Diastolic 14 0.0494 0.01 70-0.08 17
0.0520-0.1205 Total 25 0.0862 -0.0233-0.0692 HDL 10 0.0230
IDL 9 0.06 12 0.01 67-0.1057
Blood pressure
Serum cholesterol
A positive r indicates a favorable intervention outcome, with larger numbers representing larger effects. Note: CVD = cardiovascular disease, CI = confidence interval, HDL = high-density lipoprotein, LDL = low-density lipoprotein, BMI = body mass index (kg/m2).
Nutrition Reviews@, Vol. 59, No. 7 209
Table 3. The Number of Correlation Coefficients (of 11 9) Representing Each Level of the Moderating Variable for Cardiovascular Disease Risk Factors
Number of Correlation
Moderating Variable Coefticients
Age Samples with a mean age 550 years Samples with a mean age >50 years Samples that did not report mean age
Reported using a behavior theory Did not report using a behavior theory
PA-only Diet-only Combined
Compared intervention with no treatment
Compared intervention with minimal
Pre- and post-comparisons
Behavior Theory
Type of Intervention
Comparison Groups
or usual care
intervention
Follow-up Period Follow-up period of 26 months Follow-up period of <6 months
54 61 4
61 58
30 33 56
91
10 18
85 31
Note: PA = physical activity.
tions were more effective than PA-only interventions in reducing blood pressure. PA-only interventions only mea- sured PA outcomes, and these interventions produced correlation coefficients comparable with combined inter- ventions in increasing PA. In addition, diet-only and com- bined interventions were equally effective in reducing to- tal serum cholesterol and dietary fat.
Comparison groups. The majority of studies reviewed compared an intervention group with a no-treatment or a usual-care control group, making the examination of cor- relation coefficients by type of comparison difficult. No consistent pattern in effect size was noted when studies compared an intervention group with a no-treatment con- trol group, an intervention group with a minimal interven- tion group, or pretreatment with post-treatment scores (not shown in Table 4). The majority of studies used random assignment, with randomization occurring at the level of the patient, health care provider, or clindsite.
Follow-up period. Several long-term intervention studies included in this review reported on several CVD outcomes at multiple time periods, which contributed to the large number of correlation coefficients for longer- term studies. Intervention effects were generally greater for PA when the follow-up period was <6 months than
Table 4. Mean Effect Sizes ( r ) for Cardiovascular Disease Risk Factors by Moderating Factors Systolic Blood Total Serum
Physical Activity BMI or Weight Dietary Fat Pressure Cholesterol
Mean sample age 150 years
>50 years
Behavior theory No theory specified
Theory specified
Type of intervention PA-only
Diet-only
PA + Diet
Follow-up period <6 months
26 months
n r (95% CI)
(0.060.11) 19 0.08*
17 0.12* (0.07-0.16)
14 0.11*
23 0.09* (0.05-0.16)
(0.07-0.12)
26 0.09*
0
11 0.11*
(0.07-0.12)
(0.05-0.16)
14 0.13*
23 0.08* (0.09-0.17)
(0.05-0.1 1)
n r (95% CI)
8 0.07
13 0.09* (4.01-0.15)
(0.024.16)
11 0.06*
11 0.11* (0.00-0.12)
(0.034.19)
2 0.07
7 0.16*
13 0.05*
(-0.06-0.20)
(0.01-0.30)
(0.01-0.08)
3 0.14
19 0.08* (4 .22450)
(0.03-0.13)
n r (95% CI)
(0.07-0.14)
(0.04-0.26)
12 0.11*
7 0.15*
8 0.16*
13 0.10* (0.10-0.21)
(0.05-0.l5)
0
12 0.13*
9 0.11* (0.0s-o.18)
(0.05-0.17)
9 0.13*
12 0.11* (0.08-0.18)
(0.060. 17)
n r (95% CI)
5 0.07*
9 0.05* (0.05-0.09)
(0.01-0.09)
8 0.04*
6 0.08* (0.01-0.07)
(0.05-0. 12)
2 0.03
0 (-0.13-0.18)
12 0.06* (0.03-0.09)
2 0.05
12 0.06* (-0.38-0.47)
(0.03-0.09)
n r (95% CI)
10 0.05*
15 0.11* (0.01-0.1 1)
(0.060.15)
17 0.08*
8 0.10* (0.04-0.12)
(0.03-0. 18)
0
14 0.09*
11 0.09* (0.04-0.13)
(0.03-0.15)
3 0.07
19 0.08* (-0.17432)
(0.04-0.12)
* P c0.05. A positive I' indicates a favorable intervention outcome, with larger numbers representing larger effects. Note: CI = confidence interval, PA = physical activity, BMI = body mass index (kg/m2).
210 Nutrition Reviews", Vol. 59, No. 7
when the follow-up period was 26 months. Otherwise, ef- fects of shorter- and longer-term follow-up periods were similar. It is important to note, however, that the number of correlation coefficients contributing to BMI, SBP, and to- tal serum cholesterol means for shorter follow-up periods was small, and these findings should therefore be inter- preted with caution.
Discussion
Major Findings To our knowledge, this is the first review to examine the magnitude of effects of PA and dietary intervention stud- ies delivered in health care settings. Overall, these inter- ventions tended to produce modest but statistically sig- nificant effects for PA or exercise, dietary fat, weight loss, blood pressure, and serum cholesterol. The discipline of study and existing scientific literature should dictate the interpretation of effect size magnitude.lSJ6 Whereas small by conventional statistical definitions,61 these findings are likely to be meaningful when considered from a public health perspective. Clinical settings offer a way to reach a large proportion of the population, especially when low- income community health care clinics are included. CVD risk factors, many of which are reduced by increased PA and improved diet, are prevalent in the United States and other countries.62 In addition, these effects were seen even though the intensity of interventions reviewed tended to be modest, often involving brief behavioral counseling by a health care provider and printed educational materi- als. Finally, PA and dietary assessments are subject to considerable measurement error, which attenuates true correlation coefficients. In fact, probably owing to the difficulty of implementing lengthy assessments in health care settings, many ofthe measures of PA and diet used in these studies were single-item or very brief inventories. The true magnitude of effect is likely to be larger than reported here.
Intervention effects were generally larger for samples with a mean age >50 years. CVD risk factors increase with age and interventions are therefore likely to show a greater impact on the populations most in need of change. In addition, for PA in particular, interventions with <6 months of follow-up tended to have greater effects. This finding is consistent with the commonly reported declines in ad- herence to PA over time and high dropout rates. It also suggests that the factors and interventions that initially promote PA may be different from those that sustain PA over time, and that health care-based interventions should strive to address behavior maintenance.
The fact that combined interventions had similar ef- fects on total serum cholesterol, PA, and dietary fat as single-behavior interventions is important. It suggests that interventions are not “diluted” when they focus on more
than one behavior simultaneously. It was surprising that studies reporting the use of a behavior theory to guide the intervention did not generally lead to stronger effects, except perhaps for weight loss and blood pressure. It is possible that other interventions did, in fact use behav- ioral principles but the authors of these studies did not specifically report the use of these principles. Alterna- tively, the brief nature of most of the interventions re- viewed might not allow for behavior theories to have a major impact.
Finally, a number of studies were tailored to the par- ticipants’ stage of readiness for change and included brief follow-up contact (e.g., mailings, telephone contacts). Many of the studies in our review that produced larger correlation coefficients included tailoring to stage of readi- ness for change or to ethnic group and follow-up con- tacts.
Interventions with Persons of Color Ofthe studies reviewed, the vast majority included a small percentage of persons of color or none at all. In the inter- vention by Hyman et al.,” 80% ofthe sample was persons of color. The intervention was aimed at reducing dietary fat in two public health clinics. The control group received brief physician dietary counseling, whereas the interven- tion group received four diet classes and computer-inter- active telephone calls. Although the intervention group showed a reduction in serum cholesterol levels, the differ- ences between groups for serum cholesterol, dietary fat, and body weight were not significant.
Two additional interventions that were reviewed, the Southeast Cholesterol ProjecP and the North Carolina WISEWOMAN Project,58 were conducted with ethnically diverse samples of low-income individuals (5 1 % and 4 1 % of the participants were persons of color, respectively). The Southeast Cholesterol Project used the “Food for Heart Program,” which consists of a dietary risk assess- ment, clinician counseling materials, and culturally spe- cific patient education materials for individuals of low SO-
cioeconomic status from the southern United States. This project was conducted in 2 1 low-income community and rural health centers. Clinicians were randomized to pro- vide either usual care or a dietary intervention that in- cluded clinician dietary counseling, culturally specific educational materials, referral to a dietitian at 4 months if cholesterol remained elevated, and referral for drug treat- ment at 7 months if cholesterol remained elevated. Signifi- cant improvements were noted for total serum cholesterol, LDL, and dietary change. Further, correlation coefficients tended to be larger than those reported for our overall review.
Similarly, the North Carolina WISEWOMAN Project was conducted at Breast and Cervical Cancer Early Detec- tion Program sites. This project compared the delivery of
Nutrition Reviews”, Vol. 59, No. 7 211
the “New Leaf’ program (an enhanced intervention based on the “Food for Heart Program” that included three inter- vention counseling sessions with printed educational materials) with a minimal intervention (CVD risk assess- ment, and referrals and counseling as indicated). Thus, this program was also culturally tailored and designed for individuals of low socioeconomic status. Although the enhanced intervention produced larger effects than the minimal intervention for dietary change, the two groups were not significantly different for other CVD outcomes. However, significant pre-post changes in CVD outcomes occurred for both groups, and the correlation coefficients were often larger than reported for our overall review.
Together, these two studies indicate that interven- tions that target at-risk and underserved groups can pro- duce significant effects when they are tailored to the popu- lation of interest. Clearly, more studies are needed to ad- dress the effectiveness of PA and dietary counseling de- livered in health care settings with financially disadvan- taged and ethnically diverse individuals.
Study Limitations Although a number of benefits to computing effect sizes exist, limitations to the use of effect sizes are well de- scribed by Glass and colleagues and summarized by Wolf.15 First, conclusions drawn by comparing and aggre- gating studies that include different measuring techniques, definitions of variables, and participants raise difficulties.I5 In our review, the structure and delivery of the interven- tions varied greatly, as did participants (including by coun- try of residence), and very few studies used the same diet and PA outcome measures. For example, some studies as- sessed minutes per week exercised, whereas others as- sessed whether or not the person could be classified as regularly active. These issues were more pronounced than they would be, for example, in drug eficacy studies, where outcomes may be more standard (e.g., blood pressure). Second, meta-analysis techniques have been criticized for mixing “poorly” designed studies with “good” studies, which may attenuate or exaggerate outcomes, depending on the type of threats to ~a1idity.l~ In this study, we did not code for study quality. The vast majority of studies were randomized clinical trials, however, rather than quasi- experimental designs. Third, significant findings are more likely to be published than nonsignificant findings, which may bias results. Finally, multiple results from the same study (i.e., results that are not independent) may make the results appear more reliable than they truly are. Although we tried to limit the number of effect sizes in our review by, for example, averaging across different measures of the same construct (e.g., different scales used to assess PA), some studies still contributed multiple effect sizes to the analyses.15 Finally, if moderating factors are associated (e.g., if diet-only studies also tend to be short term), re-
sults of analyses by moderating factors may not provide an accurate description of the role of the moderating fac- tor. Thus, we recommend that to develop an intervention for health care settings, it is prudent to examine the com- ponents of the reviewed studies, the participant charac- teristics, and the outcomes to determine whether the in- tervention is likely to be feasible and effective.
Summary
This study was unique in that it examined the magnitude of the effects of dietary and PA interventions delivered in health care settings in reducing CVD risk factors. Our analyses indicate that these interventions, on average, were effective. Although intervention effects tended to be modest in size according to standard criteria, they were generally statistically significant and likely to be of sig- nificance to public health. A nationwide goal is to elimi- nate gender, ethnic, socioeconomic, and other disparities in health by the year 20 1 0.2 Health care settings have great potential for helping to reduce disparities in CVD risk fac- tors and outcomes. Most adults visit their health care pro- vider at least once a year.63 The few studies done to date with persons of color show promising results in reducing CVD risk factors. A common component of these studies is that the interventions are culturally relevant and tai- lored to the target population. Additional studies con- ducted in a range of health care settings, serving diverse patient populations, and addressing the longer-term main- tenance of health behavior change will be invaluable in better understanding how to improve the health of our nation.
Acknowledgements
The Heart Healthy and Ethnically Relevant Tools (HHER Tools) study was supported through a grant from the Cen- ters for Disease Control and Prevention, U48/CCU409664- 07. We wish to thank Tameka Byrd, Elizabeth Fore, Rose Marie Hendnx, Roger Sargent, Denethia Sellers, Lynn Tho- mas, Natasha Thompson, and Julia Watkins for their con- tributions to the project. We also thank Carol C. Ballew for her assistance with the HHER Tools study and her com- ments regarding this manuscript.
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