Behavioural counselling in general practice for the promotion of healthy behaviour among adults at increased risk of coronary heart disease: randomised trial. Reduction of coronary heart disease risk factors in the German cardiovascular prevention study. The multifactor primary prevention trial in Göteborg, Sweden. Primary prevention of chronic disease in childhood: changes in risk factors after one year of intervention. Coronary heart disease prevention in childhood: one-year results of a randomized intervention study. Multiple risk factor intervention trial. Risk factor changes and mortality results. Multiple Risk Factor Intervention Trial Research Group. The efficacy of multiple risk factor intervention in treated hypertensive men during long-term follow up. Risk Factor Intervention Study Group. Implementing clinical guidelines in the treatment of hypertension in general practice. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment, education, counseling, and incentives.
To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease.
                Cluster randomised controlled trial.
                883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity.
                Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity.
                Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months.
                Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months. No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation.
                Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge. In six regions of former West Germany, a community-oriented prevention program for coronary heart disease (CHD) was conducted over a 7-year period.
                In the intervention regions, CHD prevention activities were performed with special emphasis on healthy nutrition, increased physical activity, and reduction of smoking, hypertension, and hypercholesterolemia. The impact of these activities on CHD risk factor trends was observed in three independent samples of the intervention regions. Three independent representative samples of the total West German population were used as a reference. Linear regression models with interaction terms to represent the intervention effects were used to test for differences in risk factor trends.
                In the pooled intervention regions, a net reduction in mean values of systolic (-2.0%) and diastolic (-2.0%) blood pressure, total serum cholesterol (-1.8%), as well as the percentage of smokers (-6.7%) was observed compared with the nationwide trend. From the major CHD risk factors, only body mass index was not influenced in the intervention population.
                The community-oriented German Cardiovascular Prevention program can effectively be used to reduce CHD risk factors in a broad population. The effect of a multifactorial intervention programme on coronary heart disease (CHD), stroke incidence and total mortality was determined in a random sample of men, 47-55 years old at entry. The intervention group comprised 10 004 men, and the two control groups were of similar size. The intervention consisted of antihypertensive treatment in subjects with screening blood pressure above 175 mmHg systolic or 115 mmHg diastolic, dietary advice to men with serum cholesterol levels above 260 mg per 100 ml (= 6.8 mMol l-1), advice to stop smoking to subjects who smoked more than 15 cigarettes per day. The intervention was applied for 10 years during which time CHD and stroke incidence and mortality were followed by means of special registers. Participation rate at first screening examination was 75%. The risk factor levels, i.e. blood pressure, serum cholesterol and smoking decreased markedly during 10 years in the intervention group, but also among the control groups. Total mortality, stroke and CHD incidence did not differ significantly between the intervention group and any of the two control groups. We conclude that a decrease has taken place in all three major risk factors for CHD in the general male population in Göteborg, Sweden. Strategies other than intervention on high-risk individuals must be chosen if a major impact on disease incidence is to be achieved in the general population. A five-year intervention study of the feasibility and effectiveness of a program aimed at the primary prevention of chronic disease was initiated in 1980 among children in 22 elementary schools in the Bronx, New York. Schools randomly were assigned either to the intervention program or to a control group. The intervention program consists of a curriculum focusing on nutrition, physical fitness, and cigarette smoking prevention. The study population at baseline comprised 2,283 fourth-graders. Subjects were eligible at baseline and at one-year follow-up for participation in a medical examination in which the following target risk factors were measured: systolic and diastolic blood pressures, plasma total and high-density lipoprotein (HDL) cholesterol, serum thiocyanate, ponderosity index, triceps skinfold thickness, and postexercise pulse recovery rate. After one year of intervention, systolic pressure increased less in the intervention group than among controls. Diastolic pressure decreased in both groups, but more in the intervention subjects than in controls. Total cholesterol decreased in the intervention group while increasing among controls. Significant net changes in the favorable direction also were observed for total cholesterol/HDL cholesterol ratio and for thiocyanate. These observations indicate that it is feasible to implement a school-based program aimed at the primary prevention of chronic disease. The intervention program appears to have had a favorable effect on several target risk factors. Although the effects were relatively small, intervention programs in schools may prove to be effective in lowering chronic disease risk. A six-year intervention study of the feasibility and effectiveness of a program aimed at the primary prevention of coronary heart disease (CHD) has been initiated among children in six school districts in Westchester County, New York. Schools randomly were assigned either to the intervention program or to a control group. The intervention program consists of a curriculum focusing on nutrition, physical fitness, and cigarette smoking prevention. The study population at baseline comprised 1,822 fourth-graders. This paper presents the findings at baseline and at one-year follow-up for the following target risk factors: systolic and diastolic blood pressure, plasma total and high-density lipoprotein (HDL) cholesterol, serum thiocyanate, ponderosity index, triceps skinfold thickness, and postexercise pulse recovery rate. After one year of intervention, the program was found to be acceptable to school administrators, teachers, parents, and children. Small net changes in the favorable direction were observed for diastolic blood pressure and thiocyanate. Intervention programs in schools may, after sufficient duration, prove to be effective in lowering CHD risk. The Multiple Risk Factor Intervention Trial was a randomized primary prevention trial to test the effect of a multifactor intervention program on mortality from coronary heart disease (CHD) in 12,866 high-risk men aged 35 to 57 years. Men were randomly assigned either to a special intervention (SI) program consisting of stepped-care treatment for hypertension, counseling for cigarette smoking, and dietary advice for lowering blood cholesterol levels, or to their usual sources of health care in the community (UC). Over an average follow-up period of seven years, risk factor levels declined in both groups, but to a greater degree for the SI men. Mortality from CHD was 17.9 deaths per 1,000 in the SI group and 19.3 per 1,000 in the UC group, a statistically nonsignificant difference of 7.1% (90% confidence interval, -15% to 25). Total mortality rates were 41.2 per 1,000 (SI) and 40.4 per 1,000 (UC). Three possible explanations for these findings are considered: (1) the overall intervention program, under these circumstances, does not affect CHD mortality; (2) the intervention used does affect CHD mortality, but the benefit was not observed in this trial of seven years' average duration, with lower-than-expected mortality and with considerable risk factor change in the UC group; and (3) measures to reduce cigarette smoking and to lower blood cholesterol levels may have reduced CHD mortality within subgroups of the SI cohort, with a possibly unfavorable response to antihypertensive drug therapy in certain but not all hypertensive subjects. This last possibility was considered most likely, needs further investigation, and lends support to some preventive measures while requiring reassessment of others. To examine the feasibility and efficacy of a multifactorial intervention programme directed towards hypercholesterolaemia, smoking, and diabetes mellitus in treated hypertensive patients after more than 3 years' follow-up and to describe the incidence of cardiovascular complications.
                Open, randomized, parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care.
                Outpatient clinic in a city hospital.
                A total of 508 male patients with treated hypertension, aged 50-72 years, with at least one of the following: serum cholesterol > or = 6.5 mmol L-1, smoking or diabetes mellitus.
                Individually given advice and group meetings based on nutritional advice and behavioral treatment principles. Drug therapy could be instituted to achieve the treatment goals in the intervention group: serum total cholesterol below 6.0 mmol L-1, no smoking, and HbA1c below 6.0%. Diastolic blood pressure below 90 mmHg was the treatment goal in both groups.
                Serum cholesterol, HbA1c, diastolic blood pressure, smoking. Cardiovascular end-points were recorded.
                The net changes were (change intervention--change usual care): serum cholesterol -5.0% (95% confidence interval, -7.6 to -2.3%), 17.6% more stopped smoking (P = 0.04); diastolic blood pressure and HbA1c remained unchanged. The incidence of stroke was lower in the intervention group compared with the usual-care group: 2.0 and 6.7%, respectively (P = 0.017).
                The intervention programme was comparatively successful with regards to the effects on hypercholesterolaemia and smoking habits. An unexpected decrease in the stroke incidence was observed in the intervention group compared with the usual-care group. Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs. 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs. 87.1%), cardiovascular inheritance (79.5% vs. 73.4%) and body mass index (81.5% vs. 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures. This study reports an efficacy trial of four work-site health promotion programs. It was predicted that strategies making use of behavioral counseling would produce a greater reduction in cardiovascular disease risk factors than screening and educational strategies.
                Twenty-eight work sites were randomly allocated to a health risk assessment, risk factor education, behavioral counseling, or behavioral counseling plus incentives intervention. Participants were assessed before the intervention and at 3, 6, and 12 months.
                Compared with the average of the health risk assessment and risk factor education conditions, there were significantly higher validated continuous smoking cessation rates and smaller increases in body mass index and estimated percentage of body fat in the two behavioral counseling conditions. The behavioral counseling condition was associated with a greater reduction in mean blood pressure than was the behavioral counseling plus incentives condition. On average among all groups, there was a short-term increase in aerobic capacity followed by a return to baseline levels.
                Work-site interventions that use behavioral approaches can produce lasting changes in some cardiovascular risk factors and, if implemented routinely, can have a significant public health impact.
Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations. Risk factor declines were modest but owing to marked unexplained heterogeneity between trials, the pooled estimates are of dubious validity. Evidence suggests that health promotion interventions have limited use in general populations.