If Behavioral Counseling Doesn’t Work, What Then? – Patients Must Decide To Change

I used to feel as though I was beating my head against a wall trying to motivate my patients to quit smoking, eat healthy foods, and lose weight.  While my more experienced partners shrugged their shoulders and said “It’s up to them,” I was certain that I just needed to try harder.  I would comb journal articles for the latest technique and then despair that I had neither the time or the resources to try these ideas.

Most of my patients who changed their behaviors seemed to do so for their own reasons, not mine.  The medical evidence cited by the US Preventative Task Force and Cochrane Collaborative matches my experience.  When I reflect on this, it makes sense.  Each of us must find our own motivation.  I eat healthy food, run, and bike in hopes of dodging my family history of high blood pressure.

I have not stopped trying, but I have shifted my approach.  I am ready to help you, when you are ready to change.  Let’s work together to find what motivates you.

Essential Evidence Plus:

The U.S. Preventive Services Task Force recommends against routine behavioral counseling in primary care settings to promote a healthful diet and physical activity as primary prevention for cardiovascular disease in patients without hypertension, diabetes, or hyperlipidemia (grade C recommendation, moderate certainty of a small net benefit). Though seemingly harmless, counseling that is largely ineffective has an opportunity cost, in that it may prevent other, more helpful services from being provided. As primary care office visits get more crowded with effective preventive care services there is less room for ineffective interventions, no matter how seemingly easy or well-meant. (LOE = 5)


Moyer VA, on behalf of the U.S. Preventive Services Task Force. Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S.Preventive Services Task Force recommendation statement. Ann Intern Med 2012;157:367-372.

Synopsis: This guideline focuses on adults without a known diagnosis of hypertension, diabetes, hyperlipidemia, or cardiovascular disease. Although there is a strong correlation between a healthful diet, physical activity, and the incidence of cardiovascular disease, there is not good evidence that behavioral counseling — even high intensity — results in change in diet or exercise or has any meaningful effect on risk factors such as blood pressure, lipid levels, or glucose tolerance. The guidelines suggest that some patients who are ready to change and have the social support and community resources to support the change may benefit from counseling, at least theoretically. In a related recommendation, the task force recommends screening for obesity and treating patients with intensive behavioral interventions (Ann Intern Med 2012;157:373-378).

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

The Cochrane Collaborative reached the same conclusion


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