Counseling Multiple Behavioral Changes Better Than Sequential

Dr. Hyman stated that, "There are multiple behaviors people have to change for primary or secondary prevention, and getting people to change is tough.” "There seems to be a deep-seated belief among physicians that if someone has multiple behaviors to change, then you should work only on one at a time. But there is surprisingly little evidence to support that. So it occurred to us that if there are so many people who need to change so many things, why not see if there is a difference?"

Hyman and colleagues randomly assigned 289 African American patients aged 45 to 64 years who had hypertension and were smokers to one of three groups that encouraged them to: stop smoking, reduce their sodium intake to less than 100 mEq/L per day, and increase physical activity by at least 10 000 pedometer steps per week.

The first group received one in-clinic counseling session on all three behaviors every six months, plus motivational telephone calls for 18 months; the second group followed a similar protocol but addressed a different behavior every six months; and the third group received usual care, consisting of a one-time referral to existing group classes. After six, 12, and 18 months, urine and blood samples were obtained, blood pressure was taken, and behavioral changes were assessed.

The primary end point was the proportion in each arm that met at least two of the three criteria after 18 months. A total of 230 participants completed the full study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point.

"Unfortunately," Hyman admitted that, "there wasn't really any remarkable behavioral change in the study, but it didn't look like one at a time was superior and, if anything, it looked like asking for everything at once was better."

"The goals we set were pretty ambitious," he added, "and because not many people achieved [the primary end point], we decided to also look at trends for single behavioral goals, and these consistently favored the simultaneous group."

 For example, after six months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care groups had reached the urine sodium goal (p=0.01). After 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care groups tested negative for urine cotinine (p=0.08), an indication that they had stopped smoking.

"We have to admit, that although the evidence is limited and we still need far better ways to get individuals to change behavior, there doesn't seem to be any reason not to try everything at once," Hyman concluded. "There's no harm in a little internal consistency at times—if you're trying to eat right, does it really make much sense to be smoking a cigarette?"

Source: Diabetes In Control: Hyman DJ, Pavlik VN, Taylor WC, et al. Simultaneous vs sequential counseling for multiple behavioral change. Arch Intern Med 2007; 167:1152-1158.