• Several brief dietary assessment questionnaires have been validated for use in the primary care setting.  These instruments can identify dietary counseling needs, guide interventions, and monitor changes in patients' dietary patterns. However, these instruments are susceptible to the bias of the respondent. Therefore, when used to evaluate the efficacy of counseling, efforts to verify self-reported information are recommended since patients receiving dietary interventions may be more likely to report positive changes in dietary behavior than control patients.
• Effective interventions combine nutrition education with behaviorally-oriented counseling to help patients acquire the skills, motivation, and support needed to alter their daily eating patterns and food preparation practices. Examples of behaviorally-oriented counseling interventions include teaching self monitoring, training to overcome common barriers to selecting a healthy diet, helping patients to set their own goals, providing guidance in shopping and food preparation, role playing, and arranging for intra treatment social support. In general, these interventions can be described with reference to the 5-A behavioral counseling framework.

1. Assess dietary practices and related risk factors.
2. Advise to change dietary practices.
3. Agree on individual diet change goals.
4. Assist to change dietary practices or address motivational barriers.
5. Arrange regular followup and support or refer to more intensive behavioral nutritional counseling (e.g., medical nutrition therapy) if needed.

• Two approaches appear promising for the general population of adult patients in primary care settings:

1. Medium-intensity face-to-face dietary counseling (two to three group or individual sessions) delivered by a dietitian or nutritionist or by a specially trained primary care physician or nurse practitioner.
2. Lower-intensity interventions that involve 5 minutes or less of primary care provider counseling supplemented by patient self-help materials, telephone counseling, or other interactive health communications.

However, more research is needed to assess the long-term efficacy of these treatments and the balance of benefits and harms.

• The largest effect of dietary counseling in asymptomatic adults has been observed with more intensive interventions (multiple sessions lasting 30 minutes or longer) among patients with hyperlipidemia or hypertension, and among others at increased risk for diet-related chronic disease. Effective interventions include individual or group counseling delivered by nutritionists, dietitians, or specially trained primary care practitioners or health educators in the primary care setting or in other clinical settings by referral. Most studies of these interventions have enrolled selected patients, many of whom had known diet-related risk factors such as hyperlipidemia or hypertension. Similar approaches may be effective with unselected adult patients, but adherence to dietary advice may be lower, and health benefits smaller, than in patients who have been told they are at higher risk for diet-related chronic disease.
• Office-level systems supports (prompts, reminders, and counseling algorithms) have been found to significantly improve the delivery of appropriate dietary counseling by primary care clinicians.
• Possible harms of dietary counseling have not been well defined or measured. Some have raised concerns that if patients focus only on reducing total fat intake without attention to reducing caloric intake, an increase in carbohydrate intake (e.g., reduced-fat or low-fat food products) may lead to weight gain, elevated triglyceride levels, or insulin resistance. Nationally, obesity rates have increased despite declining fat consumption, but studies did not consistently examine effects of counseling on outcomes such as caloric intake and weight.
• Little is known about effective dietary counseling for children or adolescents in the primary care setting. Most studies of nutritional interventions for children and adolescents have focused on non-clinical settings (such as schools) or have used physiologic outcomes such as cholesterol or weight rather than more comprehensive measures of a healthy diet.

• This recommendation applies to adults aged 18 years or older in primary care settings who are overweight or obese and have known CVD risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome). In the studies reviewed by the USPSTF, the vast majority of participants had a BMI greater than 25 kg/m2.
• Most studies evaluated interventions that combined counseling on a healthful diet and physical activity and were intensive, with multiple contacts (which may have included individual or group counseling sessions) over extended periods. Interventions involved an average of 5 to 16 contacts over 9 to 12 months depending on their intensity. Most of the sessions were in-person, and many included additional telephone contacts. Interventions generally focused on behavior change, and all included didactic education plus additional support. Most included audit and feedback, problem-solving skills, and individualized care plans. Some trials also focused on medication adherence. Interventions were delivered by specially trained professionals, including dietitians or nutritionists, physiotherapists or exercise professionals, health educators, and psychologists.
• Many types of intensive counseling interventions were effective. However, it was not clear how the magnitude of the effect was related to the format of the intervention (for example, face-to-face, individual, group, or telephone), the person providing the counseling, the duration of the intervention, or the number of sessions because different combinations of components were effective. Because of the intensity and expertise required, most interventions were referred from primary care and delivered outside that setting.
• The USPSTF defines behavioral counseling interventions as preventive services that are designed to help persons engage in healthy behaviors and limit unhealthy ones. The USPSTF previously described the challenges of developing behavioral counseling recommendations that are feasible for primary care delivery or available for referral from primary care and delivered in other settings.
• Two well-researched interventions, the DPP (Diabetes Prevention Program) and PREMIER, could feasibly be adapted and delivered in the primary care setting or by local community providers. These interventions are described in further detail because they can be provided by an appropriately trained counselor (typically a dietitian, nutritionist, health educator, or psychologist) and their materials are publicly available.
• The DPP focused on whether weight reduction through a healthful diet and physical activity could prevent or delay the onset of type 2 diabetes. Participants in the lifestyle intervention group received intensive training in diet, physical activity, and behavior modification from a case manager or lifestyle coach. Lifestyle coaches were dietitians or persons with a master's degree and training in exercise physiology, behavioral psychology, or health education. Participants received basic information about nutrition, physical activity, and behavioral self-management. The program addressed problem solving and strategies to deal with eating at restaurants, stress, and lapses. Participants and coaches engaged in face-to-face sessions at least once every 2 months and talked by telephone at least once between visits. The DPP study documents, including coach and participant materials, are available online in English and Spanish (https://dppos.bsc.gwu.edu/web/dppos/lifestyleThis link goes offsite. Click to read the external link disclaimer). At least 1 trial included in the review 12 used an adapted DPP lifestyle intervention in patients recruited from a primary care setting. The trial was conducted in a large multispecialty group practice. Investigators tested a coach-led intervention and a home-based, DVD-facilitated intervention, as well as a Web-based portal for goal setting and self-monitoring. The materials used for the intervention are available online from the University of Pittsburgh Diabetes Prevention Support Center (www.diabetesprevention.pitt.eduThis link goes offsite. Click to read the external link disclaimer).
• PREMIER tested whether counseling on comprehensive lifestyle changes could prevent or control high blood pressure. Participants in the intensive intervention group were counseled over 6 months to track their diet (including calorie and sodium consumption) and physical activity and received printed materials about blood pressure and lifestyle changes. In addition, they were taught to follow the Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in fruits, vegetables, and low-fat dairy products and emphasizes reduced intake of saturated and total fat. The intervention was delivered by dietitians or health educators with a master's degree. The materials from this intervention, including participant manuals, food and fitness guides, and food diaries, are available online at www.kpchr.org/research/public/premier/premier.htm. Information about the DASH diet is available from the National Heart, Lung, and Blood Institute.