We now know that around 60% of all cases presenting to primary care have a lifestyle or environmentally related cause, requiring significant changes to behaviours such as diet and exercise for effective long-term management.

But realistically, how easy is it to prompt these changes at the clinical level? And how much time is needed in a consultation to cope with the rising tsunami of chronic disease? Surely, where a pharmacological solution – even of the palliative form – is available it would be more time-effective for a clinician to prescribe this.

The Chronic Disease Management (CDM) items have been designed to assist in this process, providing incentives for care planning, reviews and team care arrangements with allied health professionals. Still, the question remains as to whether lifestyle-change prescriptions work and what level/time commitment is required to make an intervention likely to be successful.

The evidence from a large number of diabetes intervention trials going back to the early Finnish studies is reasonably convincing. They show reduced risk factors and the delay of progression from pre-diabetes to type 2 diabetes with an intensive lifestyle-change intervention.

Indeed, there is a remarkable consistency in these data showing that an average of around 60% more test subjects than controls who take up 1-4 lifestyle changes (quitting smoking, changing diet, increasing physical activity and managing stress), don’t progress to full-blown diabetes over a 2-4 year period.  The figures rise to over 90% for those adopting all changes.

Recent data from the long-term Da Qing study in China have also shown that such intensive interventions can have effects that remain for up to 14 years.

Generally however, these programs have been administered in large-scale community-based trials, where cost effectiveness is feasible. It would be difficult to duplicate the input required at the clinical level, where time is particularly of the essence.

Brief interventions provide an option for doing this. But to date there’s only limited data on their effectiveness, and outcomes vary depending on the type of intervention required.  Hence now may be the time for a sober analysis of their effectiveness.

By far the most studied – and effective – brief interventions have been for smoking, alcohol and drug use. Smoking led the way on this with reports of 5-10% success rates with high quality interventions. And although this may not sound like much, it’s quite significant when compared with other approaches. Some positive findings also come from diabetes and diabetes risk factor management, depression, anxiety, gambling and even weight management.

Some consistencies are beginning to emerge in the characteristics of brief interventions that appear to be most effective across risk factors and chronic disease categories. Motivational interviewing skills of the clinician particularly stand out, but the implications from this – the need to quickly recognise and target individual idiosyncrasies, particularly in relation to the stage of change of the patient – are paramount.

Focusing on behaviour change principles – goal setting, self-monitoring, feedback, barrier identification, social support and problem solving – all increase the prospects of success. A focus on screening to provide objectification of a lifestyle problem and increasing self-efficacy (or at least ‘health efficacy’ in this case), or belief in the patient’s ability to succeed in carrying out a (health related) task, can also add to the chances of success.

Moderators that improve the chances of a positive outcome include educational level – the higher the level the greater the prospects, the number of follow-up visits, the literacy of appropriate educational materials matching the health literacy of the patient, and the presence of a supportive partner, family or immediate social circle.

With the emphasis on containing health costs, and with the prevalence of chronic diseases requiring more and more ongoing management, better use of clinical processes for dealing with these is likely to become as important as content knowledge about diseases and their cause. I’ve previously discussed the use of Shared Medical Appointments (SMAs) as a possible adjunct process for managing the lifestyle-related load of chronic disease in these pages.

A skill set in brief interventions might be yet another requirement of the modern clinician faced with the difficult problem of lifestyle change in the modern diseasogenic environment. Unfortunately, the task doesn’t get easier.

Some relevant references on Brief Interventions

  • Chen CP  et al. Development and preliminary testing of a brief screening measure of healthy lifestyle for diabetes patients. Int J Nurs Stud.2013 Jan;50(1):90-9.
  • McNaughton JL. Brief interventions for depression in primary care. Can Fam Physician 2009;55:789-96.
  • Murray E. Screening and brief intervention for alcohol use disorders in primary care. BMJ 2013, Jan 9;346:e8706.
  • National Obesity Observatory. Brief interventions for weight management.  Solutions for Public Health, 2011.
  • Roy-Burne P et al. Brief intervention for anxiety in primary care patients. J Am Board Fam Med 2009;22:175-86.