Paper: Assessment of Lifestyle in Relation to Health

After pioneer behavioral medicine research demonstrated how behavior can influence health and how modifying behavior can affect health outcomes [1], an increasing body of evidence links the initiation and progression of several medical disorders to lifestyle and behavior [2‒4].

Recently, the need to redesign primary care practice by incorporating health behavior change and information about health-promoting behaviors has been underscored [5, 6]: half of the deaths that take place in the US can be attributed to chronic diseases that are all heavily influenced by ‘largely preventable behaviors and exposures’ [7].

Consequently, there is growing awareness that contemporary medicine needs to focus on lifestyle changes for primary prevention, for secondary intervention, and to empower patients’ self-management of their own health behaviors [8].

Humans naturally form ‘habits’ or ‘style’, which are recurrent and often unconscious patterns of behavior [9]. Any behavior in which control and choice are impaired is abnormal by definition and thus a source of clinical concern. Curt Richter [10] first discussed the concept of motivated behaviors: motivated (driven) behaviors develop through a combination of (a) specific physiological features, which stimulate the drive and respond to its satisfaction with (b) learning, which is the result of the influence of the environment on the responses generated by the drive. Craving drives (derived from powerful physiological impulse) combined with conditioned learning, overwhelm an individual's capacity to direct and modify his or her actions [11].

Behaviors relevant to health include physical activities, diet, sleeping, smoking, drinking and drug consumption [12]. Disorders of such motivated behaviors could come either from some disarrangement of the drive mechanisms or from a maladaptive life experiences that misled the learned response patterns [11]. There are several aspects that McHugh and Slavney take into account to define a disordered behavior [11]. A disordered behavior may, for example, be tied to its goals. Alcohol dependence can be seen as behaviors with disordered goals. The means to getting to a goal represent another way in which a behavior can be deviant and disordered. Examples may include the use of dangerous sedatives for sleep. The consequences of some behaviors identified them as dangerous and injurious. Examples include lung cancer from cigarette smoking, and coronary artery disease and obesity with high-fat dietary preferences [11].

As remarked by Wise [5], poor healthy behaviors may be worsened also by psychosocial variables that affect health and contribute to the prevalence of comorbid anxiety and depression in primary care populations. For example, demoralization in the primary patient, if untreated, often promotes unhealthy attitudes and behaviors such as substance abuse or lack of compliance [5]. These examples, however, constitute a small minority of the behavioral problems requiring explanation and treatment. More frequent are those behaviors that emerge in individuals who have no obvious diseases or defects [11]. Physicians, psychiatrists, psychologists should question how to interrupt these dangerous behaviors or, when that proves too difficult, protect people from their unhealthy consequences [11]. According to this need for behavior modification, a constant interplay between assessment and therapeutic strategies should be promoted. Measurement of lifestyle behaviors is thus necessary for the identification of causal associations between unhealthy lifestyle and health outcomes, description and quantification of the dose-response relationships between lifestyle and health outcomes, documentation of changes and differences in unhealthy lifestyles within and between individuals, respectively, over time, formulation of public health recommendations, the validation of intervention programs, and comparison of unhealthy lifestyles levels between populations, particularly when cultural and language differences exist.

However, despite considerable evidence for the importance of the assessment of lifestyle and therapeutic lifestyle changes in both clinical and normal populations, it still is underutilized [13‒16].

Kanfer and Saslow [17] commented on traditional methods of data collection for behavioral analysis: the patient's verbal report, his non-verbal behavior during an interview and his performance on psychological tests. To evaluate behaviors in clinical practice, the authors [17] stated that, not only clinimetric and psychometric assessments are essential to do behavioral analysis: if one views behavior disorders as sets of response patterns which are learned under particular conditions and maintained by definable environmental and internal stimuli, an assessment of the patient's behavior only based on the verbal report remains insufficient for a complete analysis and for prediction of his daily behavior. ‘... a functional approach of behavior has the advantage that it specifies the causes of a behavior in the form of explicit environmental events which can be objectively identified and which are potentially manipulable...’ [18, p. 3]. Kanfer and Saslow [17] thus suggested a series of data categories as essential in order to help the clinician in the collection and organization of information for a behavioral analysis. This list involves the analysis of the problem situation (frequency, intensity, duration, appropriateness), the circumstances where the problem appears (antecedents, consequences for the patients and the others in his environment), the motivational aspects associated with the problem (analysis of the reinforcing stimuli), the patient's characteristic behavioral development and patient's deficits and excesses of self-controlling behaviors. To determine what resources can be used and limitations must be considered during the treatment, also a sociocultural-physical environment analysis should be done.

Standardized interviews and tests may collect behavioral samples of the patient's reaction to a real problem situation in a relatively stressful interpersonal setting. Psychological tests can thus gather not only quantitative scores but they can also be treated as a small-scale life experience, yielding information about the patient's interpersonal behavior and variations in his behavior as a function of the nature of the stimulus conditions [17]. In this chapter, we will examine the methods of behavioral assessment and standardized tools for those lifestyles (physical activity, dietary intake, smoking and alcohol consumption) currently declared by international guideline recommendations to be the major preventable risk [19].

Variations on traditional testing procedures should be also obtained by using role playing, discussion, and interpretation of current life events. Observations of interaction with significant others can also be used for the analysis of variations in frequency of various behaviors as a function of the person with whom the patient interacts. The patient may be asked to provide samples of his/her own behavior by using tape recorders for the recording of segments of interactions in his family, at work, or in other situations during his everyday life [17].

The role of dietary factors in the development of chronic disease is not fully acknowledged and is based mostly on indirect data [14]. However, epidemiologic evidence suggests that unhealthy dietary parameters are associated with increased risk for obesity, type 2 diabetes, and heart disease [20‒22], and a change in dietary choice seems to reverse or moderate the disease burden of some common risk factors related to coronary heart disease, diabetes, some cancers, and stroke [23]. Today, assessing diet intake and enhanced adherence to dietary guidelines are recommended [24].

The goal of dietary and nutritional assessment should be to identify appropriate and pragmatic areas of change in dietary lifestyle [25]. A primary nutritional assessment should take no more than 5-15 min, and it should obtain the following information: relevant laboratory and anthropometric data and the patient's current diet. Cultural and behavioral factors that are pertinent to a patient's food choices should also be evaluated [25, 26].

Anthropometric data should include the patient's body mass index [BMI = body weight (in kg) ÷ stature (height, in meters) squared] and the body fat distribution (a local predominant abdominal fat increases the risk of complications such as metabolic syndrome and coronary heart disease) [22]. Recommended laboratory data should include total cholesterol, HDL, triglycerides and LDL. Supplemental and specific lab test may be appropriate in assessing the nutritional state in special population such as Crohn's disease, colitis, diverticular disease, renal disease and patients who present unexplained gastrointestinal distress, anemia or unintentional weight loss [25, 26].

A complete dietary and nutritional assessment then provides for obtaining relevant information from the current diet. This will help determine which dietary lifestyle changes are reasonable for a given patient and any beneficial dietary habits that may be increased. Diet intake can be evaluated directly and indirectly [14]. Direct measures are aimed at counting the absolute amount of habitual diet intake. There are several methods used to assess dietary intake directly: dietary records, 24-hour dietary recall, food frequency, brief dietary assessment instruments, diet history, blended instruments [27]. Indirect methods to assess habitual dietary intake consist of trying to measure an indicator of the amount of habitual diet intake through, for example, biological markers [14]. The combination of different methods probably would give the most valid estimate [14]. The most common direct methods to assess habitual diet in a clinical setting are presented in this review. For more details, see Thompson and Subar [27].

The dietary record method has the potential for providing quantitatively accurate information on food consumed during a recording period [26, 27]. For the dietary record approach, the respondent records the foods and beverages and the amounts consumed over one or more days. The amounts consumed may be measured using a scale or household measures (such as cups, tablespoons), or estimated using models, pictures. Recording periods of more than 4 consecutive days are discouraged because of respondent fatigue [28, 29]. At the end of the recording period, a trained interviewer should review the records with the respondent to clarify entries and to probe for forgotten foods. Since the information should be recorded at the time of the eating occasion, the awareness of recording food may alter the dietary behaviors the tool is intended to measure [27]. This effect is a weakness when the aim is to measure unaltered dietary behavior. However, when the aim is to enhance awareness of dietary behavior and change that behavior this effect can be seen as an advantage. Recording, by itself, has been shown to be an effective weight loss technique [29]. Pilot study testing this approach found improved self-monitoring and adherence to dietary goals [30].

A brief nutritional assessment tool commonly used in clinical setting is the 24-hour dietary recall. For the 24-hour dietary recall, the respondent is asked to remember and report all the foods and beverages consumed in the preceding 24 hours or in the preceding day. The rationale behind the utility of this instrument is that most people have little variability in dietary habits and are remarkably consistent with caloric intake and food choices. The recall typically is conducted by interview, in person or by telephone [31, 32], either computer assisted [33] or using a paper and pencil form. The 24-hour recall is probably the best-described quantitative method to assess dietary intake [14, 31]. An abbreviated assessment may be performed by obtaining only the previous evening's intake (the evening is when the majority of calories are consumed). Because there is relatively little burden on the respondents, the 24-hour recall method is useful across a wide range of populations. In addition, interviewers can be trained to capture the detail necessary by avoiding leading questions and helping in reporting portion sizes. In contrast to other record methods, dietary recalls occur after the food has been consumed, so there is less potential for the assessment method to interfere with dietary behavior [27]. The main weakness of the 24-hour recall approach is the high rate of underreporting: factors such as obesity, gender, social desirability, restrained eating, education, literacy, perceived health status, and race/ethnicity have been shown in various studies to be related to underestimation [27, 34‒36].

If the clinician is especially short on time, another assessment tool for diet intake is the Food Frequency Questionnaire (see online suppl. appendix), which is the quickest way to identify dietary patterns. Used in combination with the 24-hour recall, this is the best way to identify protective and detrimental components of the patient diet. The food frequency approach [27, 37] asks respondents to report their usual frequency of consumption of each food from a list of foods (100 categories) and frequency of use response categories (usually over an extended period such as last 3 months or last year) in order to collect a qualitative, descriptive and non-quantitative information about habitual food consumption [14]. Clinicians should focus on one or more key diet areas that are correlated with their patient's health concerns [38]. Food frequency assessment can also reveal what is missing in the diet. This information is equally important from a clinical point of view. The major limitation of the food frequency approach method is that it contains a substantial amount of measurement error [14, 27] and the difficulty in making the distinction between frequency and quantity [14].

OSM

Urine, blood, breath, hair, saliva, and sweat are all types of lab tests for drug consumption. Urine testing is most widely used because it is noninvasive, simple to obtain, and yields a detectable concentration of most drugs; however, it does not measure impairment. Blood levels of drugs can provide more information about level of impairment, but must be obtained invasively, and drug metabolism may shorten the time in which a drug can be detected in the bloodstream, compared to urine sampling. The best evidence for long-term drug use is the combination of a good history and a urine toxicology screen [ 176].

Clinicians continue to be the most respected source of lifestyle modification information [15]. A number of psychological treatments have been found to be effective in health-damaging behaviors [ 177]. A basic psychosomatic assumption is the consideration of patients as partners in managing disease. The partnership paradigm includes collaborative care (a patient-physician relationship in which physicians and patients make health decisions together) [178, 179] and self-management (a plan that provides patients with problem-solving skills to enhance their self-efficacy) [180, 181].

The assessments of lifestyle are underutilized despite considerable evidence of their effectiveness in both clinical and normal populations [8]. Methods for assessing lifestyles were presented in this review. To evaluate behaviors in clinical practice via interview, not only clinimetric and psychometric assessment is essential. Behavioral analysis should also include functional analysis of behavior. Several validated developmental and behavioral instruments that are easily and briefly administered are available. Questionnaires are typically chosen for population studies because they possess the characteristics of non-reactiveness (they do not alter the behavior of the individual being surveyed), practicality (there are reasonable study costs and participant convenience), applicability (the instrument can be designed to suit the particular population in question), and accuracy (it is both reliable and valid). However, currently methods to assess diet intake, physical activity, alcohol, smoking and other illicit drugs suffer from serious methodological defects such as underreporting and overreporting and the influence of cultural and social ideas in the definition of what it is considered acceptable consumption [14]. Assessment of the patient's behavior only based on the verbal report remains insufficient for a complete analysis and for prediction of his/her daily behavior; implementation of tools for assessing lifestyle has therefore been recommended [90].