1. Research
Counselling patients about behaviour change:
the challenge of talking about diet
Katie Phillips, Fiona Wood, Clio Spanou, Paul Kinnersley, Sharon A Simpson,
Christopher C Butler on behalf of the PRE-EMPT Team
Abstract
INTRODUCTION benefits with small effects on cholesterol
Rising levels of obesity are of major concern levels and other outcomes.7 This uncertain
in the UK.1 Levels of obesity in adults have evidence base is further complicated by the
risen to over 25% of men and 28% of women misinterpretation of public-health
in England.2 Although there was a general messages8 and the complex interaction
reduction in cholesterol levels between 1994 between food beliefs, attitudes towards
Background
and 2008,2 there has been little reduction in healthy eating, and associated
saturated fat intake (which is still, typically, behaviours.9,10 Furthermore, there is
above recommended levels2) and only a variability in clinicians’ confidence in raising
As obesity levels increase, opportunistic
small increase in daily fruit and vegetable and providing adequate information.11-13
behaviour change counselling from primary
portions.2 Rising levels of obesity impact on A useful structure to follow when
care clinicians in consultations about healthy
morbidity and mortality, particularly in considering providing patients with
eating is ever more important. However, little is
Aim
known about the approaches clinicians take
relation to cardiovascular disease; information is to think about what is said to
with patients.
consequently, health promotion and patients (the content) and then how this
behaviour change consultations are information is provided; this is called the
To describe the content of simulated
increasingly important. process of information provision.14 To
consultations on healthy eating in primary care,
Clinicians in primary care are well placed improve how health professionals provide
Design and setting
and compare this with the content of smoking
to provide opportunistic and cost-effective advice, researchers have adapted behaviour
cessation consultations.
behaviour counselling about healthy eating change techniques for healthy eating
and weight reduction.3,4 Patients consult counselling, derived from motivational
Qualitative study of 23 audiotaped simulated
their GP on average 5.5 times a year5 and, if interviewing.3,15 Successful use of this
healthy eating and smoking cessation
clinicians do not engage in health technique regarding reducing alcohol intake
consultations between an actor and primary
care clinicians (GPs and nurses) within a
promotion there is the risk that patients and quitting smoking suggests this
Method
randomised controlled trial looking at
assume there are no concerns.6 Smoking approach could be used for dietary
behaviour change counselling.
levels have dropped in the UK over the last concerns.16 However, how information is
decade, whereas obesity rates have risen;2 provided is unlikely to lead to significant
Consultations were audiotaped and transcribed
talking about healthy diets, physical activity, change if there is a lack of clarity regarding
verbatim, then analysed inductively using
and other factors relating to obesity are, what dietary changes to recommend and
thematic analysis. A thematic framework was
therefore, a pressing challenge. implement.
developed by all authors and applied to the
data. The content of healthy eating
Implementing dietary changes to reduce The PRE-EMPT (Preventing disease
Results
consultations was contrasted with that given for
weight and cholesterol is challenging. through opportunistic, Rapid Engagement
smoking cessation.
Studies have explored individual factors, by Primary care Teams using behaviour
such as increasing one’s intake of fruit and change counselling) study designed an
There was a lack of consistency and clarity
vegetables and reducing saturated fats, salt, intervention using behaviour change
when clinicians discussed healthy eating
and sugar; most reports show limited counselling derived from motivational
compared with smoking; in smoking cessation
consultations, the content was clearer to both
the clinician and patient. There was a lack of
specificity about what dietary changes should
be made, how changes could be achieved, and
how progress could be monitored. Barriers to
change were addressed in more depth within
Conclusion
the smoking cessation consultations than
within the healthy eating encounters.
K Phillips, MRCGP, associate academic fellow; Public Health, Neuadd Meirionydd, University
At present, dietary counselling by clinicians in F Wood, PhD, lecturer; P Kinnersley, MD FRCGP, Hospital of Wales, Heath Park, Cardiff, CF14 4XW.
primary care does not typically contain professor, Institute of Primary Care and Public E-mail: phillipsk15@cardiff.ac.uk
consistent, clear suggestions for specific
Health; SA Simpson, PhD, senior research fellow; Submitted: 23 August 2011; Editor’s response:
change, how these could be achieved, and how
CC Butler, MD FRCGP, professor and director of 11 October 2011; final acceptance:
progress would be monitored. This may
Institute of Primary Care and Public Health,
Keywords
contribute to limited uptake and efficacy of 9 November 2011.
dietary counselling in primary care. Cardiff University, Cardiff. C Spanou, PhD, senior ©British Journal of General Practice
lecturer, Psychology and Mental Health,
This is the full-length article (published online
Staffordshire University, Stoke-on-Trent.
27 Dec 2011) of an abridged version published in
communication, behaviour change counselling; Address for correspondence
commnication; healthy eating; primary care. print. Cite this article as: Br J Gen Pract 2012;
Katie Phillips, Cardiff University, Primary Care and DOI: 10.3399/bjgp12X616328
e13 British Journal of General Practice, January 2012

2. How this fits in
complemented by a further seminar on
skills and strategies. To complete the
training, the clinicians in the intervention
group undertook an audiotaped
consultation with an actor. Six months later,
a further simulated consultation occurred
for clinicians in the intervention arm,
Obesity is a growing problem and clinicians
enabling feedback on their use of behaviour
need to discuss healthy eating with
change counselling.
patients as effectively as possible. This
study shows that, in contrast with smoking
Clinicians in the intervention group were
cessation consultations, clinicians lack
asked to choose one of the four behaviours
clarity and consistency in the advice they
to discuss during the simulated training
give patients about dietary change.
consultations. Four scenarios had been
Stressing the shorter-term, more
developed3 and different actors played each
immediate benefits of dietary change, and
scenario. This consultation was undertaken
the close monitoring of change seem to be
at clinicians’ surgeries during a normal
particularly important.
interviewing for use by clinicians. The clinic session and audiotaped and
primary aim was to examine the efficacy of transcribed verbatim.17
using such counselling during The purpose of the research study
consultations by reporting the proportion of reported here was to test the content of
patients making changes in one or more of what was discussed in smoking cessation
four behaviours: smoking, alcohol intake, consultations compared with that discussed
eating, and exercise.3 in the healthy eating consultations. Eleven
Although the emphasis of the PRE-EMPT transcripts were available for the scenario
trial was on how practitioners advised of a patient who had a raised cholesterol
patients through recordings of simulated level and was overweight, with the
consultations by clinicians, it also provided counselling focus to be on healthy eating.
an opportunity to study what advice was Twelve transcripts were available for the
given. This article reports on an analysis of scenario of a young woman who was
audiotaped consultations between pregnant and continuing to smoke.
simulated patients, and GPs and nurses,
which enable a contrast between the Analysis of simulated consultations
content of smoking cessation and healthy The audiotaped simulated training
eating consultations to be made. consultations were transcribed and
anonymised by a researcher not further
METHOD involved in this study. Data analysis followed
The PRE-EMPT study a thematic approach.18 After initial
The method of this cluster randomised inspection, a thematic framework was
controlled trial has been reported developed by one of the researchers; this
elsewhere.3 Twenty-nine general practices was discussed and modified by the
in Wales were recruited and randomised to research team. Five main thematic
usual care or to the intervention arm; one categories emerged:
doctor and one nurse from each practice
participated. The intervention involved • what change would be beneficial;
clinician training in behaviour change • how to change;
counselling using a blended learning • how change would be demonstrated and
programme. The main trial focused on four monitored;
risk behaviours: smoking, excess alcohol
• what the benefits of change would be;
intake, low physical activity levels, and
and
unhealthy diets. After training in behaviour
change counselling for the intervention • barriers to change.
group, each practice in both arms of the
trial recruited up to 40 patients; primary The data were then coded according to
outcomes were patients’ self-reporting the framework. A second researcher
behaviour change at 3 months. double-coded a third of the transcripts to
check levels of agreement.
Simulated consultation generated from Both the initial and 6-month simulated
the intervention training consultations were included in the analysis.
The blended training for the main trial It was decided that data analysis would not
included a seminar at the practice followed match consultations for each clinician in
by an e-learning programme. This was instances when the scenario was repeated.
British Journal of General Practice, January 2012 e14

3. Data analysis focused on clinician talk P: I mean it’s how it’s [food] cooked I
relating to change within the five thematic suppose, it’s all greasy stuff and … I suppose
categories. The actors are referred to as that’s a big factor in it [improving diet] if
patients within this study because the that’s the case with cholesterol. But I just
intention was that they should be as similar don’t know how to address that really …
as possible to real patients. C: Well, really, as I said, if we were focusing
on the dietary sort of things, it’s, as I said, to
RESULTS be aware of what cholesterol is, what foods
Exemplary data extracts from the simulated contain the cholesterol and just try and
consultations are used to illustrate key address it from that point of view really.
themes. There was no notable difference in (Healthy eating 7)
content between consultations in the first
phase of the study and those repeated after Although some clinicians discussed only
6 months. diet, others mentioned changes in diet
Smoking cessation consultations took a within a context of more general lifestyle
mean time of 7.9 minutes to conduct during changes, such as increasing exercise:
a routine surgery (range: 5.4–9.4 minutes).
Consultations about healthy eating were, C: Um, and then you can have a think as
typically, longer and took a mean time of well about, um, you know, areas in your —
12.2 minutes (range: 6.2–21.4 minutes). you know diet and exercise is very much
linked and perhaps we can make another
What to change appointment for you to come back in and
Discussing what to change within the have a chat about exercise.
smoking cessation consultations provoked (Healthy eating 4)
a universal agreement that stopping
smoking completely was the ideal goal: A few clinicians also addressed weight as
a factor that would be influenced by both
Clinician (C): So you’re keen to cut down dietary changes and increasing exercise,
and, ideally, stop? and as important factor in reducing the risk
Patient (P): Ideally, yeah. of cardiovascular disease.
(Smoking 4)
How to change
For the healthy eating consultation there Unsurprisingly, given that what to change
was less agreement between clinicians was clear, many of the smoking cessation
regarding what to change; some offered no consultations focused on how to achieve the
specific advice on what to change in the diet, desired target of stopping smoking. In most
focusing more on an assumption of the consultations, in line with the e-learning
patient’s prior knowledge of what programme, discussion included eliciting
constituted healthy eating: how confident the patient was about stopping
smoking, and advice was given regarding
C: I suppose what I would say is that most setting targets and dates. Previous
people consume a bit more bad diets than experiences with smoking cessation were
what they think they do, and I bet that if I got discussed and individual problems
you to write a list of things you thought were addressed. The emphasis was on individual
bad on one sheet of paper and [a] list [of] preferences to make it work for the patient.
what you thought were good on another Most clinicians challenged personal and
sheet you wouldn’t be far off the mark. It’s social perpetuating factors. Therefore,
about how you incorporate that into your discussion on how to change was detailed
daily routine … and consistent. Discussion on how to quit
(Healthy eating 11) was patient centred in the majority of
consultations and reflected a complex
Other clinicians concentrated on reducing behaviour, of which the patient was clearly
fats in a diet or increasing fruit and vegetable aware:
intake, and a few consultations took the
approach of advocating balanced diets with a C: What have you done to try and cut down
discussion of which foods to increase or so far? What kind of things have you
avoid. There was little similarity between managed to do?
clinicians in what was recommended, P: Just breaking the routine sometimes, you
compared with the consultations on know, when I feel like one [a cigarette] it’s
smoking cessation, and advice on what to just willpower isn’t it, you know? That’s why
change was often unclear or superficial: I haven’t managed to cut it out totally
e15 British Journal of General Practice, January 2012

4. because I haven’t found that willpower The example above shows that the
enough ... clinician is trying not to direct, but rather to
C: So I wonder if, whether we can have a engage, the patient in addressing lifestyle
think of some other ways that we can help issues and guide them through the
you try and stop completely. process of initiating change. This is
(Smoking 3) consistent with the behaviour change
counselling training received on how to
Medication and advice regarding cravings discuss the topic, but the narrow focus on
were discussed, although smoking cheese illustrates that what is being
cessation services were not always offered. discussed is limited for both patient and
Some clinicians provided written clinician.
information to the patient. Dietary advice was often supported by
The healthy eating consultations also written information sheets, which the
included information on how to change, but patient could take home.
this was more variable and delivered in a Advice on how to increase exercise was
variety of ways. Clinicians advised eating in offered during two consultations using
moderation, eating a balanced diet, having divergent approaches. One clinician offered
smaller portions, or being organised and advice on how to increase opportunities
planning meals in advance. Some clinicians within an existing lifestyle, while the other
referred the patient to a dietician or practice recommended an average quantity of
nurse for specific food information. It was exercise that should have an impact on the
notable that, in contrast with the smoking patient’s health each week.
cessation consultations, in which patients
were encouraged to find their own How change is demonstrated and
solutions, in the healthy eating monitored
consultations the clinicians were quick to In the smoking cessation consultations
come up with solutions for patients: clinicians offered options for regular review,
which was either arranged fortnightly
P: But it’s like you say, I’ve got to find the (especially if starting medication) or as
healthy alternatives really, haven’t I? required and to be determined by the
C: Yeah and, um, if you can’t take it [your patient. Goals were left to the patient, but
lunch] with you, I mean you could probably the message of setting a target of cutting
take some fruit with you, if you’re worried down, with an endpoint of stopping, was
about it, you know, going off, if you’re out clearly communicated in all the smoking
and about all day. cessation consultations:
P: Yeah.
C: And you can buy those little cool bags C: So, what would be your … what’s your
can’t you with, um, the little coolers to put in, next goal? What’s your next plan?
to help keep the food cooler if you’re taking P: Well, I’m on about, I think I’m smoking
sandwiches or salads, um, so I think, you about 10 a day, so … I reckon I’d cut down by
know, to start with that, you know, that’s ... about half anyway … I mean, like I say, I
see how you go. would like to stop altogether …
(Healthy eating 10) (Smoking 4)
Some clinicians focused on increasing Most clinicians felt that reviewing dietary
the intake of fruit, vegetables, and fibre; changes with a follow-up consultation was
others included more specific advice on important; repeating cholesterol tests was
foods within the ‘bad’ and ‘good’ categories: the main focus for monitoring. The timing of
repeating this test, however, ranged from
P: I do have a lot of margarine but I do eat between 1 month and 6 months, with no
quite a lot of cheese because I like cheese. formal follow-up planned for the interim
C: OK, right. So if you were to sort of cut period. The wide range of time given by
down on, obviously cheese is quite full of … various clinicians for follow-up depended on
quite a lot of fat. the interim specified for repeating
P: Yeah, yeah. cholesterol testing and reflected an
C: So how would you feel about maybe uncertainty and lack of clarity on how to
cutting down on the cheese? further manage the case:
P: Yeah, yeah I could do that … um, what,
would it be advisable to put something in its P: So when would be the best time to have
place instead of it? another check?
(Healthy eating 9) C: I think if, what we tend to do is to give you
British Journal of General Practice, January 2012 e16

5. 3 months, um, to maybe take this home, or socially, clinicians took these:
have a look at your diet and the drinking,
um, just look at small changes, reasonable P: Perhaps my mum should think about it
changes that ... I mean you might like to as well.
chat with your wife, talk them through, C: Yeah, yeah, yeah. I mean if mum, could
something reasonable, um, and then maybe give up as well, then you will be doing it
we can re-do your cholesterol in about together.
3 months’ time? (Smoking 8)
(Healthy eating 4)
Within the healthy eating there was less
A few clinicians, however, suggested emphasis on the benefits of change for the
weight loss as a means of monitoring individual. Clinicians focused on the
change, proposing monthly reweighing at importance of preventing heart disease and
the surgery as a way of maintaining stroke generally, but often without clear
motivation and demonstrating change: reference to individual risk profiles for that
particular patient.
C: The other incentive I try to make is, if The second point noted with all clinicians
people want to lose weight if they want to was that, although major longer-term
come and just weigh once a month. benefits for reducing cholesterol levels and
P: Oh right. eating healthier diets were discussed,
C: To see if they are sticking to their diet and shorter-term gains were not used as an
to see if that’s any help because, obviously, incentive. In the smoking interactions,
the weight loss will help as well. changes in smells and finances were strong
(Healthy eating 3) immediate benefits with the goal of a
longer-term healthy pregnancy, baby, and
Benefits of change better health in the future. There was no
The benefits of stopping smoking were apparent parallel discussion for the healthy
discussed in terms of benefits to the patient eating consultations:
and her pregnancy and baby. All clinicians
discussed antenatal risks associated with P: OK. I mean how dangerous is it? I mean
smoking, focusing on growth restriction and I, I — it just worries me when I hear about
underweight babies at delivery. Childhood things.
asthma was addressed in most C: Yeah, of course, yeah. It’s not detrimental
consultations, which was an opportunity for in that it’s life threatening right now, it’s
clinicians to express the importance of usually ... cholesterol builds up in your
continued cessation after pregnancy. In this arteries over a long period of time, so, you
scenario, the patient reported being aware know for somebody your age, you know, we
of risks to her health from smoking; in are looking sort of 10, 15 years, you know,
some consultations, however, the down the line.
cardiovascular risks were reiterated and the P: Yeah.
benefit of smoking cessation quantified. C: Some possible damage to the coronary
Financial benefits and the benefits of arteries.
reducing stigma associated with smoking P: Right.
were also raised: C: So, you know, every small step you take
right now will definitely help to, you know,
C: What sort of negatives, would you say, sort that problem out and get it [cholesterol
could you see with your smoking? Is there level] lower a bit.
anything in particular you dislike about your (Healthy eating 5)
smoking?
P: I don’t like, well, obviously, I don’t like the The simulated patient presented to the
fact that I’m pregnant now and I’m still study with a family history of high
doing it and it can harm my baby, so that’s cholesterol and cardiovascular disease;
the biggest thing, but I also don’t like the however, the importance to the patient of
fact that I smell to other people. I’m modifying this risk behaviour was often not
constantly chewing mints and all of that delivered:
because I don’t like, I hate that, you know,
the smell of it. C: OK. Um, how do you feel about the fact
(Smoking 1) that your father has got high cholesterol
and the implications that it might have on
If opportunities arose to promote you?
smoking cessation among others at home P: Um ...
e17 British Journal of General Practice, January 2012

6. C: Long term, I mean now. negatively affected patients’ confidence in
P: I haven’t really thought about it, um ... I their ability to successfully initiate any new
mean he hasn’t had any problems. changes. Whereas the clinicians appeared
C: Hasn’t he, no? to anticipate barriers to smoking cessation,
P: No, but [it’s] only initially that he has been in the healthy eating consultations they used
told he has high cholesterol. fewer opportunities to discuss
(Healthy eating 5) accommodating change:
Those clinicians who discussed exercise C: I mean, obviously, you’ve got a lot going
within the consultation mentioned both the on at the moment, you’ve got two jobs and,
short- and long-term benefits of increasing you know, busy active life at the moment so,
exercise. This had more similarities with maybe if things calm down in a few months
discussions that took place in the smoking we can, you know, you can come back and
cessation consultations than the healthy we can go through things again at a later
eating ones. date and, you know, if you’re ready then to
make some changes to look at your diet and
Barriers to change lifestyle and we can, you know, sort of make
The smoking cessation consultations some, put some plans in action for you.
provoked discussion from both clinicians (Healthy eating 5)
and patients regarding the problems
associated with quitting. These included DISCUSSION
physical addiction, and fears of cravings and Summary
weight gain on stopping. Positive aspects of This qualitative analysis identifies particular,
smoking were raised by both clinicians and complex challenges of discussing healthy
patients, including enjoyment, relaxation, eating compared with smoking cessation in
and the fact that it is often sociable and a primary care consultations. This could
explain the longer consultations recorded
part of routine and habit. Clinicians
for healthy eating interactions.
demonstrated an ability to address these
Although all clinicians were trained to
barriers, drawing solutions from the patient
improve how behaviour change is discussed
in line with behaviour change counselling:
with patients, there were clear differences
P: I do enjoy smoking.
regarding what was discussed. In the
C: Is it a social thing?
smoking cessation consultations, the
P: It is a social thing. Most of my friends
clinician and service user were both clear on:
smoke. Um, my mum smokes and I live with • what to change;
my mum.
C: Right … Well that’s quite difficult then. • how to change and monitor this;
P: So yeah, so it’s kind of like, you know, it’s • what the barriers were; and
in the house so it’s not really when I go out • the benefits of change.
with my friends, it’s in the house as well, my
mum smokes. Um, so that’s it really, they There was less consistency and clarity in
are then negatives because I do enjoy it and, consultations regarding healthy eating.
as I say, my friends and stuff. So it is quite a Individual clinicians focused on different
social thing. elements of dietary change and gave
C: Do you think it would affect your idiosyncratic advice on how change could be
relationship with your family and your achieved, thereby directing, rather than
friends if you give up? Is that something guiding, patients.
that’s in your mind? Monitoring was not clearly planned in the
P: I would, I suppose. Maybe it wouldn’t healthy eating consultations. Benefits of
affect it … healthy eating were presented for longer-
(Smoking 2) term health gains, in all but one
consultation, without reference to benefits
The healthy eating consultations also that could encourage the patient in the
raised discussions regarding barriers to shorter term, such as weight loss if the
change. The time involved with planning patient were overweight.
meals, shopping for fresh food, and in food Clinicians appeared less able to
preparation was perceived as an extra task anticipate and discuss barriers to dietary
within an already full lifestyle and, therefore, change than to smoking cessation.
difficult to maintain. Access to fresh, healthy
food was also discussed. Previous diets not Strengths and limitations
maintained were seen as experiences that This study is limited by the use of simulated
British Journal of General Practice, January 2012 e18

7. consultations. However, the simulated Comparison with existing literature
patients did consult during routine clinical Clinicians in primary care have
sessions and had no ‘out-of-role’ acknowledged that smoking cessation
interaction with the clinicians, which adds consultations are straightforward, whereas
considerable authenticity to the process. there is more variability in the
Feedback confirmed that the consultations conceptualisation of those related to
were accepted as authentic by the healthy eating.11 They have been identified
clinicians within the study. These clinicians as differing consultations — success for
may already have had an interest in smoking is measured as an absolute
behaviour change, be research minded (smoking cessation), but success for
and, thus, atypical of primary care healthy eating traverses along a
clinicians; in addition, they had all continuum, measured by various factors
undergone training in behaviour change (such as weight loss11 and reduced
counselling. The topic was chosen by the cholesterol level). The current study is in
clinician and may have been a perceived agreement with others that suggest a need
area of strength, leading to improved for clinicians to improve their knowledge20
performance in the consultation; and more detailed assessments of patients’
conversely it may also have been a weaker eating habits and perceptions of food and
area in which they hoped to improve. health.8
The patient-generated content of the Current literature reports that, beyond
consultation may lack originality, but what superficial screening, clinicians are
the study does provide is a measure of reluctant to discuss healthy eating and
clinician management of a standardised weight management with patients.11,12 It
consultation. Simulated consultations can has been reported that offering support and
produce realistic stress physiological setting follow-up for weight loss and
responses in clinicians and can, therefore, healthy eating consultations is done
be realistic.19 The clinician-initiated poorly.21 These points are mirrored within
material within the consultation is this study.
comparable between consultations and, Two trials have reported little effect in
Funding consequently, data analysis has focused on cholesterol reduction as a result of dietary
The PRE-EMPT study was funded by the the clinicians’ talk. advice interventions.22,23 Uptake of healthy
National Prevention Research Initiative with A patient with high cholesterol levels was diets and reductions in cholesterol levels
support from the following organisations: used in this scenario as a model for a were more sustained when patients were
British Heart Foundation; Cancer Research consultation in which healthy eating advice aware of illnesses and more motivated to
UK; Chief Scientist Office, Scottish was needed. This was the pre-designed change. These reports emphasise the
Government Health Directorate; scenario, but offers a realistic scenario that potential of focusing on the benefits of
Department of Health; Diabetes UK; occurs on a frequent basis in primary care. change,24 and personalising risk and gain
Economic and Social Research Council; The patient in the scenario was overweight; for individuals that may increase motivation
Health & Social Care Research & this may not necessarily be the case in and sustain change. This study confirms
Development Office for Northern Ireland; reality and highlights the importance of that benefits of changes in diet are often not
Medical Research Council; Welsh Assembly ascertaining patient-centred goals and discussed in a way that patients
Government; and World Cancer Research short-term benefits that can result from immediately relate to, thereby failing to
Fund (reference: NPRI, G0501283). behaviour change. capitalise on motivating factors for change.
The particular scenarios used could be Although clinicians focus on the important
Ethical approval criticised for using dissimilar patients, long-term considerations and risk of
Multi-Centre Research Ethics Committee thereby reducing comparison potential. coronary or cerebrovascular disease,
for Wales, reference: 07/MRE09/11. However, it is arguable that clinician patients’ motivation, may be driven by more
Provenance knowledge of smoking cessation or healthy immediate benefits.
Freely submitted; externally peer reviewed. eating needs to be robust enough to adapt Clinician variability and lack of
to individuals’ personal circumstances; this engagement in healthy eating and weight-
Competing interests study demonstrates, overall, that there is loss consultations are associated with
The authors have declared no competing less ability to do this in the healthy eating clinicians’ varying attitudes, the stigma
.
interests. scenario than in the smoking one. relating to the issue, perceived competency
Acknowledgements The number of consultations used within in this area, and the perception of efficacy of
the analysis is small and may limit the the treatment that is available to the
The authors acknowledge the funders of the
breadth of thematic material available. patient.11,12 This study suggests that these
PRE EMPT Trial, as well as the contribution
Each clinician had two consultations with factors relate to a deficit in what clinicians
of the study clinicians and actors.
the actor and, given that no two are including within their consultation.
Discuss this article consultations are identical, including both Researchers have used techniques to
Contribute and read comments about was felt to be acceptable. The findings enhance behaviour change in healthy eating
this article on the Discussion Forum: reported were consistently represented consultations with only marginal
http://www.rcgp.org.uk/bjgp-discuss across the consultations. success.21,25 Models conceived for smoking
e19 British Journal of General Practice, January 2012

8. cessation such as the Stages of Change This lack of clarity over healthy eating
model and the American-based 5As model discussions may partially explain primary
have had translational difficulties.21,25 and care clinicians’ unsuccessful attempts to
only show small effects when used to encourage behaviour change and requires
promote healthy eating. However, what this attention if clinicians are going to make an
study indicates is that training clinicians in improved contribution to reducing obesity
how to deliver information is advancing and promoting healthy eating.
without fully exploring the lack of the Comparing healthy eating consultations
knowledge and conceptualisation of the with those on smoking cessation in terms of
problem. The two concerns, perhaps, need what is discussed in relation to change
to be addressed in relation to each other in suggests a need for improved clarity from
future research. clinicians in general practice. Guidance on
how to change diets, together with
Implications for practice and research personalising risks and benefits of change,
This conceptualisation has practical are potential areas that should be focused
implications and can help develop ways in on in order to secure improvement. The role
which clinicians can improve their ability to of behaviour change counselling to improve
motivate patients and facilitate sustained how we manage discussions regarding
improvements. Clinicians appeared less healthy eating is exciting, but unlikely to
able to anticipate and discuss barriers to succeed unless clinicians are clear about
dietary change than to smoking cessation. what information needs to be discussed.
British Journal of General Practice, January 2012 e20

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