Addressing Multiple Unhealthy Behaviors At Once May Be More Effective Than Sequential Approach

David J. Hyman, M.D., M.P.H., of Baylor College of Medicine, Houston, and colleagues randomly assigned 289 African-American patients who had hypertension and were smokers to one of three groups that encouraged them to stop smoking, reduce their sodium intake to less than 100 milliequivalents per liter per day, and increase physical activity by at least 10,000 pedometer steps per week.

The first group received one in-clinic counseling session on all three behaviors every six months, plus motivational telephone calls for 18 months; the second group followed a similar protocol, but addressed a different behavior every six 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.

A total of 230 participants completed the full study. "At 18 months, only 6.5 percent in the simultaneous arm, 5.2 percent in the sequential arm and 6.5 percent in the usual-care arm met the primary end point," or changing two of the three behaviors, the authors write. "However, results for single behavioral goals consistently favored the simultaneous group."

For example, after six months, 29.6 percent in the simultaneous, 16.5 percent in the sequential and 13.4 percent in the usual-care groups had reached the urine sodium goal. After 18 months, 20.3 percent in the simultaneous, 16.9 percent in the sequential and 10.1 percent in the usual-care groups tested negative for urine cotinine, which the body produces when it metabolizes nicotine, indicating they had stopped smoking.

"Long-term multiple behavior change is difficult in primary care," the authors conclude. "This study provides strong evidence that addressing multiple behaviors sequentially is not superior to, and may be inferior to, a simultaneous approach."

This research was reported in the June 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. (Arch Intern Med. 2007;167:1152-1158.)