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Bea Feeney of Clayton, N.C., says she has always eaten healthy. But her husband, John, is a different story.
"He liked his sweets and his chocolates and his ice cream," says Bea of her spouse, a 72-year-old Army Veteran.
Now that's changed, thanks in large part to a VA study in which the couple participated. The trial, based at the Durham VA Medical Center, included 255 Veterans and their spouses. It tested a low-cost, telephone-based intervention aimed at getting Veterans to set healthy-living goals, and enlisting their spouses to support them in the effort.
The Veterans in the intervention group received nine monthly calls from a nurse to help them set goals and create action plans. Topics included diet, physical activity, patient-doctor communication, and medication adherence.
Spouses also received monthly calls. They learned strategies they could use to support their loved ones' goals. In some cases, they changed their cooking habits or began an exercise program with their spouse.
The study did succeed in improving diet and exercise habits for the Veterans. The Feeneys are a good example."He's eating better," says Bea about John. "He'll usually have a salad for lunch. And we don't use heavy dressings—mainly olive oil and canola oil."
There was no difference between groups, however, in the study's main outcome measure. Levels of LDL (“bad") cholesterol improved equally in both the intervention and usual-care groups. Both groups had a five to seven percent reduction.
The results appeared in the journal Preventive Medicine on Nov. 9, 2012. VA Research Currents talked with lead author Corrine Voils, PhD, a social psychologist, to learn more about the study and its outcomes.
RC: The intervention improved diet and exercise, but this did not translate into better LDL outcomes in the intervention group versus the usual-care group. Do you believe a longer study would have yielded a different outcome?
CV: Yes, a longer study may have allowed us to see the longer-term effects of diet and physical activity on cholesterol levels. It may take patients longer to make dietary changes of the magnitude needed to affect LDL. However, there are several reasons why the intervention may not have improved LDL over and above the control group. For one, medications are much more potent at affecting LDL than is diet or physical activity. At the time our study was starting up, there were several medication management directives at our VA, and more effective drugs were coming to market. So it was easier to lower LDL with medication. Studies with a usual care control group typically assume that usual care will not change over time. However, usual care improved a lot in this trial.
Behavior change can be difficult. What does the study show about the best ways to achieve it?
In many studies, patients are told what to do. One of the unique aspects of this study is that we allowed patients to choose which behavior they wanted to work on and to set their own goals and action plans according to what they felt confident they could accomplish. Patients built on those goals over time. The idea is for patients to achieve a goal and feel confident so they can build on that success. This process translated to significant improvements in health behaviors during the study period. Theoretically, this process should translate to longer-term change, but future research will need to investigate this.
Do you think individuals and couples in the intervention group benefited in ways that are not reflected in the data?
Many of our patients have other chronic conditions for which dietary and physical activity changes may be beneficial, such as high blood pressure or diabetes. We did not measure the effects on those outcomes. In addition to clinical outcomes, the intervention could affect psychological processes like social support between spouses. In future analyses, we will examine whether the intervention affected social support and self-efficacy, or confidence, for diet and physical activity.
Could you share an anecdote about new habits that couples formed as a result of the study that you think they will stick to and that will benefit them in years to come.
At the end of the study, I conducted qualitative interviews with almost 30 patients and spouses who received the intervention, to learn about their experience. Anecdotally, several patients reported that they developed new habits during the study that would be easy to continue. Examples were label reading, different ways of preparing foods —for example, grilling instead of frying—and portion control. Research will need to determine whether these anecdotes are representative of the study sample and whether the changes translate to long-lasting outcomes.
The cost of the intervention per couple, $148.16, seems very modest. Was it designed specifically to be low-cost? How important is it to view the findings in light of this cost factor?
My main motivation for choosing telephone delivery was to maximize reach. One benefit is that telephone is relatively low-cost, so patients were able to receive nine 14-minute calls and spouses were able to receive nine 9-minute calls without breaking the bank. Even if the effect is small on average, or applies to only a proportion of patients, if the cost is so low, it may be worth implementing the intervention in primary care.