Simultaneous Better Than Sequential Behavioral Counseling in CVD Prevention

June 15, 2007 — Addressing more than 1 behavioral change at a time — so-called simultaneous counseling — is probably more effective than sequential counseling, which tries to tackle changes one by one, a new study has found.
Dr David J Hyman (Baylor College of Medicine, Houston) and colleagues report their findings from a high-risk group of patients with hypertension in a primary care setting in the June 11 Archives of Internal Medicine.
"There are multiple behaviors people have to change for primary or secondary prevention, and getting people to change is tough," Hyman told heartwire. "There seems to be a deep-seated belief amongst physicians that if someone has multiple behaviors to change then you should only work 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?"
No Remarkable Behavioral Change
Hyman and colleagues randomly assigned 289 African-American patients aged 45 to 64 years who had hypertension and were smokers to 1 of 3 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 1 in-clinic counseling session on all 3 behaviors every 6 months, plus motivational telephone calls for 18 months; the second group followed a similar protocol, but addressed a different behavior every 6 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 endpoint was the proportion in each arm that met at least 2 of the 3 behavioral 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 to heartwire, "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."
Single Behavioral Goals: Simultaneous Approach Much Better
"The goals we set were pretty ambitious," he added, "and because not many people achieved [the primary endpoint] we decided to also look at trends for single behavioral goals, and these consistently favored the simultaneous group."
For example, after 6 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 = .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 = .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?"
Arch Intern Med. 2007;167:1152-1158.