HEALTHY DIET (Counseling)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 9/27/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force recommends intensive behavioral dietary counseling for adults with hyperlipidemia (lipid disorders) and other known risk factors for cardiovascular and diet-related chronic diseases. Intensive counseling can be delivered by primary care clinicians or specialists such as nutritionists and dieticians.1

Evidence Rating: B (Recommended/At Least Fair Evidence)
The USPSTF found good evidence that medium- to high-intensity counseling interventions can produce medium to large changes in average daily intake of the core components of a healthy diet (including reduced consumption of saturated fat and increased consumption of fiber, fruits, and vegetables) in adult patients at increased risk of diet-related chronic diseases.1

Controlled clinical trials have assessed intensive counseling interventions for at-risk adult patients. The trials involved combined nutrition education with behavioral dietary counseling provided by a nutritionist, dietician, or specially trained primary care clinician. The USPSTF concluded that such counseling is likely to improve important health outcomes and that its benefits outweigh its potential harms. No controlled trials of intensive counseling in children or adolescents were identified that measure effective dietary counseling in the primary care setting.1

NOTE:
The USPSTF concludes that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in certain populations. For more information, see I Statements.

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The Value of Prevention

Economic Burden of Condition/Disease
Unhealthy diets contribute to several diseases that impose a heavy economic burden on employers and employees.

Obesity costs account for 5-7% of annual health expenditures, amounting to more than $100 billion per year.8 In 2005, direct medical costs of osteoporosis in the U.S. were estimated between $13.7 billion and $20.3 billion.1
Workplace Burden of Condition/Disease
Productivity losses due to cardiometabolic risk factor clustersare estimated at $17.3 billion.19

The cost to employers of obesity among full-time employees in 2008 was $73.1 billion per year, including $30.3 billion in total medical costs, $12.8 billion in absenteeism, and $30 billion in lost productivity (termed presenteeism).11 In addition, an estimated 39 million workdays are lost to obesity-related illnesses each year.12
Economic Benefit of Preventive Intervention
A randomized controlled trial of a low-cost healthy nutrition education program in the California Public Employee's Retirement System found a cost savings of 20% over 12 months.

The Massachusetts Dietetic Association found that diet modification and counseling for hypercholesterolemia by a registered dietitian saved an estimated $1,300 per patient, per year.13
Estimated Cost of Preventive Intervention
In 2004, the private-sector cost of preventive medicine counseling by a physician averaged $39 per session; approximately 95% of all paid claims fell within the rage of $0 to $129 per session.14 Nutritional counseling by a dietician averaged $61 per session and approximately 95% of all paid claims fell within the range of $0 to $150 per session.14
Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
Nutrition education from the expanded Food and Nutrition Education Program, administered by the U.S. Department of Agriculture, helps limited-resource populations acquire the knowledge, skills, and attitudes, and make the behavior changes necessary for nutritionally sound diets. The benefit-to-cost ratio of $10.64/$1.00 for a Food and Nutrition Education Program in Virginia15 and $10.75/$1.00 in Iowa16 shows that nutrition counseling can produce a significant return-on-investment (ROI).

Another study found that an intensive nutrition intervention in patients with type 2 diabetes had a cost-effectiveness ratio of $4.20, while the cost-effectiveness ratio of usual nutrition care was $5.32.17

Some evidence indicates that lifestyle interventions may be more cost-effective than drug treatments for some diet-related chronic illnesses.18

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Condition / Disease Specific Information

Epidemiology of Condition/Disease
The relationship between dietary patterns and health outcomes has been examined in a wide range of observational studies and randomized trials with patients at risk of diet-related chronic disease. The majority of these studies have shown that people who consume diets that are low in fat, saturated fat, trans-fatty acids, and cholesterol and high in fruits, vegetables, and whole-grain products containing fiber have lower rates of morbidity and mortality from coronary heart disease and, possibly, several forms of cancer than those who consume unhealthy diets.4 In fact, 4 of the 10 leading causes of death — coronary heart disease, some types of cancer, stroke, and type 2 diabetes — are associated with unhealthy diets.1

Lipid Disorders
Nearly 107 million American adults (50.7% of the adult population) have a total blood cholesterol value of 200 mg/dl or above, and 37.7 million of these adults (18.3%) have a total blood cholesterol level of 240 mg/dl or above.5 A reading of less than 200 mg/dl is considered desirable and a reading of 240 mg/dl or more is considered high.

Obesity
Obesity is epidemic in the United States. Between 1976 to 1980 and 1999 to 2002, the proportion of obese adults doubled, the proportion of overweight children (aged 6 to 11) doubled, and the proportion of overweight adolescents (aged 12 to 19) tripled.6 Approximately half to two-thirds of obese adults have diabetes, high blood pressure, coronary artery disease, high cholesterol, or a combination of these conditions.7

Both lipid disorders and obesity are risk factors for cardiovascular diseases, including coronary heart disease and coronary artery disease.

Cardiovascular Disease
Coronary heart disease, a cardiovascular disease, is caused by arteriosclerosis (a thickening or hardening of the arteries) and can lead to angina pectoris (heart pain), heart attack, or both. An estimated 1.5 million adults have a heart attack each year in the United States. The American Heart Association estimates that 13.9 million adults have a history of coronary heart disease and about every minute, someone dies from a heart attack.5 Arteriosclerosis is particularly sensitive to lipid levels.

Alcohol and caffeine use and insufficient calcium or vitamin D intake are also risk factors for osteoporosis. Please refer to the Osteoporosis Screening and Treatment Evidence-Statement for additional information.

Cancer
The American Cancer Society estimates that almost 1.4 million new cases of cancer will develop in 2006.3 About one-third of the 564,830 deaths expected to result from cancer in 2006 are related to diet, physical inactivity, and overweight or obesity and are thus preventable.3

To reduce the risk of morbidity and mortality from coronary heart disease and to maintain a healthy weight, it is necessary to eat a healthy diet and to balance calories consumed with physical activity.1 A healthy eating plan is one that emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products; includes lean meats, poultry, fish, beans, eggs, and nuts; is low in saturated fats, trans-fats, cholesterol, salt (sodium), and added sugars; and balances caloric intake with caloric needs. The Federal publication, Nutrition and Your Health: Dietary Guidelines for Americans provides a good source of dietary advice2:
  • Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans-fats, cholesterol, added sugars, salt, and alcohol.
  • Meet recommended intake of calories within energy needs by adopting a balanced eating pattern, such as the U.S. Department of Agriculture's Food Guide or the Dietary Approaches to Stop Hypertension (DASH) eating plan.
  • Maintain a diet with less than 10% of calories from saturated fat, no more than 30% of calories from total fat, and limited consumption of trans-fatty acids.
Condition/Disease Risk Factors
Consuming a healthy diet is associated with a reduced risk of chronic disease morbidity and mortality.

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Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Behavioral counseling can help persons at high risk of cardiovascular disease and other diet-related chronic diseases improve their diets and thereby reduce their risk of the poor outcomes and complications associated with obesity, lipid disorders, and coronary heart disease.1
Benefits and Risks of Intervention
Medium- to high-intensity behavioral interventions appear to produce consistent, sustained, and clinically important changes in dietary intake of total fat, saturated fat, fruits, vegetables, and fiber.1 It is important to note that the studies supporting these benefits were conducted in patients with known risk factors for diet-related chronic disease or in special clinics with select patients and specially trained providers. The most effective interventions generally combined education, behavior-oriented counseling, patient reinforcement, and follow-up. More intensive interventions and those of longer duration were associated with greater benefits and more sustained changes in diet.1 The largest effects of dietary counseling in asymptomatic adults with hyperlipidemia or hypertension and those at increased risk of diet-related chronic disease have been observed with more intensive interventions (multiple sessions lasting 30 minutes or longer).1

Two other approaches appear promising for adult patients in primary care settings1:
  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 counseling by a primary care provider and are 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 to balance the benefits and harms.1

Possible harms of dietary counseling have not been well-defined or measured. Some researchers have suggested that a focus on reducing total fat intake but not reducing caloric intake might lead to an increased intake of carbohydrates (in the form of reduced-fat or low-fat food products), which could result in weight gain, elevated triglyceride levels, or insulin resistance.1

Little is known about effective dietary counseling for children or adolescents in the primary care setting. Most studies of nutritional interventions in these populations have focused on non-clinical settings, such as schools, or have used physiologic outcomes, such as cholesterol level or weight reduction, rather than indicators of a healthy diet, such as intakes of total and saturated fats.19
Initiation, Cessation, and Interval of Counseling
The USPSTF was not able to determine the ideal frequency of counseling. Other research has indicated that intensive counseling (30 to 45 minutes in duration) can reasonably be conducted at baseline, 3 months after the initial intervention, and every 6 months thereafter, as medically indicated. Thus, in any given calendar year, 3 counseling sessions could be provided.
Intervention Process
Decisions about behavioral counseling should take into account the overall risk for coronary heart disease. Risk assessment should consider age, sex, and the presence and severity of the following risk factors: diabetes, elevated total cholesterol levels, low levels of high density lipoprotein cholesterol, elevated blood pressure, family history (in younger adults), and smoking.1

Effective interventions include individual or group counseling, which can be delivered by nutritionists, dietitians, specially trained primary care practitioners and health educators in the primary care setting, or in other clinical settings by referral.1

Effective interventions combine nutrition education with behavior-oriented counseling to help patients acquire the skills, motivation, and support needed to alter their daily eating and food preparation practices. Examples of behavior-oriented counseling interventions include teaching self-monitoring, training patients to overcome common barriers to selecting a healthy diet, helping patients set their own goals, providing guidance in shopping and food preparation, engaging in role playing with patients, and arranging for social support during treatment. In general, these interventions align with the "5 As" behavioral counseling framework20:

  • Assess dietary practices and related risk factors.
  • Advise patients to change dietary practices.
  • Agree on individual diet change goals.
  • Assist patients in changing their dietary practices or addressing motivational barriers.
  • Arrange regular follow-up and support or refer patients to more intensive behavioral nutritional counseling (e.g., medical nutrition therapy) if needed.2,17
Systems supports (prompts, reminders, and counseling algorithms) for primary care clinicians have been found to significantly improve their delivery of appropriate dietary counseling.21

Initial assessments and follow-up monitoring can be conducted using any of several brief dietary assessment questionnaires, which have been validated for use in the primary care setting.22 These instruments identify dietary counseling needs, guide interventions, and monitor changes in patients' dietary patterns. Since patients enrolled in diet-change programs may exaggerate their adherence the programs, clinicians may not wish to rely on brief dietary assessment questionnaires but may find them useful to verify self-reported information.2,23
Treatment Information
Not Applicable

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Strength of Evidence

The level of evidence supporting the recommendations contained in this chapter is described below.
Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: B (Recommended/ At Least Fair Evidence)
  • The U.S. Preventive Services Task Force found good evidence to recommend intensive behavioral dietary counseling for adult patients with hyperlipidemia (lipid disorders) and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling may be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dieticians.1

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Summary Plan Description

Covered Counseling
Intensive behavioral dietary counseling is covered for adult beneficiaries with hyperlipidemia (lipid disorders) and other known risk factors for cardiovascular and diet-related chronic diseases.
Initiation, Cessation, and Interval
Beneficiaries who meet the criteria for counseling are eligible for 3 intensive (30-45 minute) counseling sessions per calendar year.

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CPT Codes

Healthy Diet (Counseling)
99402 Preventive medicine counseling/risk factor reduction, individual, 30 minutes
99403 Preventive medicine counseling/risk factor reduction, individual, 45 minutes
99411 Preventive medicine counseling/risk factor reduction, group, 30 minutes
99412 Preventive medicine counseling/risk factor reduction, group, 60 minutes
98960 Education and training for patient self-management by a qualified, nonphysician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
S9470* Nutritional counseling, dietician visit

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Other Information and Resources

Business Group Resource(s)

CDC Resource

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Author(s)

Cooksey C, Allweiss P, Campbell KP. Diabetes evidence-statement: screening. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006. Updated 2011.

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References

  1. U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: Recommendations and rationale. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=3494&nbr=2720. Accessed May 26, 2009.
  2. U.S. Department of Health and Human Services. Nutrition and your health: dietary guidelines for Americans, 2005 edition. Available at: http://www.health.gov/dietaryguidelines/. Accessed May 26, 2009.
  3. American Cancer Society. Cancer facts & figures 2006. Atlanta, GA: American Cancer Society; 2006.
  4. Clifford C, Ballard-Barbash R, Lanza E, Block G. Risk factors: Diet and cancer risk. Available at: http://rex.nci.nih.gov/NCI_Pub_Interface/raterisk/risks73.html. Accessed May 27, 2009.
  5. American Heart Association. Heart disease and stroke statistics: 2005 update. Dallas, TX: American Heart Association; 2005.
  6. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among U.S. children, adolescents and adults. 1999-2002. JAMA. 2004; 291:2847-50.
  7. Must A, Spandano J, Coakley EH, Field AE, Colditz G, WH. D. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-29.
  8. Ludwig, D and Pollack, H. Obesity and the Economy. The Journal of the American Medical Association. 2009; 301(5): 533-535.
  9. Sullivan, P, Ghushchyan, V and Ben-Joseph, R. The Effect of Obesity and Cardiometabolic Risk Factors on Expenditures and Productivity in the United States. Obesity. 2008; 16(9): 2155-2162.
  10. Dempster, D. Osteoporosis and the Burden of Osteoporosis-Related Fractures. American Journal of Managed Care. 2011; 17: S164-S169.
  11. Finkelstein, E et al. The Costs of Obesity in the Workplace. Journal of Occupational and Environmental Medicine. 2010; 52(10): 971-976.
  12. Thorpe KE, Florence CS, Howard DH, Joski P. The impact of obesity on rising medical spending. Health Aff. 2004;W4:480-6.
  13. National Cholesterol Education Program. Second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Washington, DC: National Institutes of Health; 1993.
  14. Thomson Medstat. Marketscan. 2004.
  15. Rajgopal, R et al. Cost-Benefit Analysis Indicates the Positive Economic Benefits of the Expanded Food and Nutrition Education Program Related to Chronic Disease Prevention. Journal of Nutrition Education and Behavior. 2002; 34(1): 26-37.
  16. Wessman C, Betterley C, Jensen H. Evaluation of the costs and benefits of Iowa's Expanded Food and Nutrition Education Program (EFNEP): final report. Available at: http://ideas.repec.org/p/ias/cpaper/01-sr93.html. Accessed May 27, 2009.
  17. Franz MJ, Splett PL, Monk A, et al. Cost-effectiveness of medical nutrition therapy provided by dieticians for persons with non-insulin-depended diabetes mellitus. J Am Diet Assoc. 1995;95:1018-24.
  18. Herman WH, Hoerger TJ, Brandle M, et al. The cost-effectiveness of lifestyle modification or Metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005;142:323-32.
  19. Obarzanek E, Kimm SY, Barton BA, et al. Long-term safety and efficacy of a cholesterol-lowering diet in children with elevated low-density lipoprotein cholesterol: seven-year results of the Dietary Intervention Study in Children (DISC). Pediatrics. 2001;107:256-64.
  20. Kontogianni, M et al. Nutrition Recommendations and Interventions for Subjects with Cardiovascular Disease. Nutrition and Health. 2009; Part 4: 221-244.
  21. Calfas KJ, Zabinski MF, J. R. Practical nutrition assessment in primary care settings: a review. Am J Prev Med. 2000;18:289-299.
  22. Paxton, A. et al. Starting The Conversation: Performance of a Brief Dietary Assessment and Intervention Tool for Health Professionals. American Journal of Preventive Medicine. 2011; 40(1): 67-71.
  23. Kristal AR, Curry SJ, Shattuck AL, Feng Z, Li S. A randomized trial of a tailored, self-help dietary intervention: The Puget Sound Eating Patterns study. Prev Med. 2000;31:380-9.