In the United States in 2002, 890 million visits were made to physician offices, or approximately 314.4 visits per 100 people (1). Because physician advice is highly valued by patients (2,3), the health care system is an optimal environment for influencing lifestyle changes. Healthy People 2010, a nationwide health promotion and disease prevention agenda (4), has set the following goals for advice to patients about health behaviors: 1) 85% of physicians will counsel their patients about physical activity, and 2) 75% of physician office visits made by patients with cardiovascular disease, diabetes, or dyslipidemia will include dietary counseling. These goals are based on evidence that poor dietary habits and a sedentary lifestyle contribute to excessive morbidity and mortality and that physician counseling for diet and physical activity is effective but not practiced often enough to have a significant impact on patient behavior (4). Since the publication of Healthy People 2010, research has continued to document low levels of physician counseling for physical activity, fruit and vegetable consumption, and weight control. Reported rates of physician counseling are as low as 28% for physical activity, 40% for nutrition, and 12% for weight loss (5-7).

Although these rates of physician counseling seem low, there are three limitations that may have affected this research. First, researchers examining physician counseling rates for these health behaviors may not have considered whether patients were already meeting guidelines (6-10). For example, if a physician appropriately assessed a patient as already meeting the guidelines for physical activity, fruit and vegetable consumption, and weight, it may not be practical for the physician to spend time counseling the patient on these behaviors. Instead, it is better use of time to counsel patients about behaviors for which they are in greatest need of advice (e.g., stress reduction, alcohol consumption). Additionally, many studies have overlooked the impact of health care professionals other than physicians on patients' lifestyle behaviors (5,8,10-12). During an office visit, a patient spends only about 10 minutes with a physician (13,14), and any additional time is spent with nurses, physician's assistants, or both. Thus, some patients not receiving advice from their physician during an office visit may be receiving it from other health care professionals. Because of these considerations, research on the prevalence of provider advice for health behavior changes should assess advice from all health care providers and include only patients who are not meeting recommendations for the health behavior of interest.

A second limitation of research on health care provider advice is that many studies have focused on predominantly white populations (5,8,10). Examining rates of provider advice for health behaviors and correlates of provider advice in African American populations is important because compared with whites, African Americans are less active, eat fewer servings of fruits and vegetables, and are more likely to be diagnosed with chronic diseases related to inactivity and overweight or obesity (15,16). Furthermore, because the annual rate of office visits for whites (334.6 visits per 100 people) is higher than for African Americans (252.9 visits per 100 people), the importance of health behavior counseling increases for each office visit made by an African American patient (1).

Third, it is important to note that few studies have examined the relationship between provider advice and patients' readiness to change (10). Because behavior change is a process that involves an individual's motivation to change and may require several attempts before long-term success is achieved (17-19)Third, it is important to note that few studies have examined the relationship between provider advice and patients' readiness to change (10). Because behavior change is a process that involves an individual's motivation to change and may require several attempts before long-term success is achieved (17-19), it is important to assess an individual's readiness to change. According to the transtheoretical model, behavior change occurs through periods of progression and relapse as an individual moves through a five-stage process: 1) precontemplation, 2) contemplation, 3) preparation, 4) action, and 5) maintenance (18,19). These five stages of change are based on current behavior, intention to change, and the time frame for behavior or intention.

The goals of this study were to 1) determine the rate of health care provider advice for healthy lifestyle changes in African Americans who do not meet recommendations for physical activity, fruit and vegetable consumption, and weight; 2) examine the correlates of provider advice such as age, education, income, sex, perceived health, and diagnosed diseases (i.e., cardiovascular disease, diabetes, high blood pressure, and high cholesterol); and 3) assess the association between provider advice and stage of change for each of these health behaviors.

Overall, participant-reported health care provider advice for healthy lifestyle changes was fairly low in African Americans not meeting recommendations. Of the participants, 47.0% were counseled for moderate to vigorous physical activity, 38.7% were counseled for fruit and vegetable consumption, and 39.7% were counseled for weight. Although the rates of health care provider advice seem to be higher than in previous reports (5-7), they still have not reached goals set by Healthy People 2010 (4). In multivariate analyses, results indicated that a higher number of diagnosed diseases and greater BMI were independently associated with receiving advice for physical activity. For fruit and vegetable consumption, a more advanced stage of change and greater number of diagnosed diseases were independently associated with receiving advice. Finally, weight, BMI, stage of change, and perceived health were independently associated with receiving health care provider advice.

The key finding of our study is that provider advice to increase healthy lifestyle behaviors was associated with the presence of patient comorbidities. Specifically, the presence of chronic diseases was the major criterion for provider advice for physical activity and fruit and vegetable consumption; participants diagnosed with at least one chronic disease were at least two times as likely to receive advice for moderate to vigorous physical activity and fruit and vegetable consumption as those with no diagnosed chronic diseases. Thus, instead of inquiring about the health behaviors themselves, it appears that health care providers are using the presence of comorbidities to guide their counseling for healthy lifestyle changes.

This interpretation that health care providers are counseling on the basis of comorbities is supported by the result that participants with a higher BMI were more likely to receive advice about weight and physical activity. Although overweight and obesity are not considered diseases, they are major risk factors for disease, and instead of counseling patients about their weight and physical activity as a preventive approach, it appears that physicians wait until a patient is overweight before counseling for physical activity and weight. BMI was not independently associated with advice for fruit and vegetable consumption in multivariate analyses. This is an important finding because healthy weight loss is most successful when simultaneously increasing physical activity and reducing caloric consumption (which is often achieved through diets promoting increases in fruits and vegetables [24,25]). Thus, our results corroborate recent evidence that many patients, providers, or both may not be making the connection between the need to lose weight and the need to simultaneously increase physical activity and eat diets high in fruit and vegetables (26).

Another important finding in this study is that, similar to other studies (6,27), a greater percentage of women reported being counseled for physical activity, fruit and vegetable consumption, and weight. Although this difference was statistically significant only for weight, these data suggest that men are less likely to receive advice from their health care providers to change lifestyle behaviors. It is possible that providers are more likely to give advice to women because they feel more comfortable counseling women or because they feel as though their advice is more effective for women than men. Another possibility is that women may be more likely to receive advice because they visit health care providers more often than men do because of gynecological and pediatric visits; women may also spend more minutes per visit with the physician (28). Alternatively, one can make the argument that the patient's sex does not moderate provider counseling but that women are more likely than men to remember being counseled or are more likely to follow provider advice (29). Future researchers can resolve these issues by investigating sex as a moderating variable for health care provider counseling as well as recording interactions between health care providers and patients rather than relying on self-reported information.

Consistent with previous research (5,6,8,12,27), older participants were significantly more likely to receive advice to increase moderate to vigorous physical activity. This association, however, was not present for fruit and vegetable consumption or weight. Furthermore, in multivariate analyses, age did not retain its independent effect on advice for physical activity. The equivocal nature of the relationship between age and provider advice may indicate the presence of a mediating variable. Providers may not specifically use age as a criterion for giving advice for behavior change but instead may use incidence of chronic disease (which increases with age).

In contrast to previous research (8,27), provider advice was not associated with education level for any of the health behaviors investigated in this study. It is important to note, however, that our sample was substantially smaller than other studies (8,27); the smaller sample size may have limited our ability to detect the effect of education on health behavior. Because of the equivocal results related to education, it is possible that the association between advice and education is mediated by the quality and frequency of health care and not directly due to the use of education level as a variable to determine whether patients are advised for health behaviors.

Finally, we found that health care provider advice was associated with readiness for change for weight loss and fruit and vegetable consumption (10). Because of the cross-sectional nature of the data, this result could be interpreted in two ways. First, it might be argued that patients moved into a higher stage of change after receiving advice from their health care provider to change behavior. It could also be argued, however, that participants in a higher stage of change may have been more likely to seek advice from their provider or that those in a higher stage of change were more likely to remember and adhere to their provider's advice. Recent research has suggested, however, that participants in a higher stage of change are more likely to seek provider advice; provider advice for lifestyle change has been shown to be an effective tool in changing physical activity and dietary behaviors (29-32).

A limitation of this study is its reliance on cross-sectional data; no cause–effect relationship between provider advice and its correlates can be established. Additionally, it is important to note the limitations of self-reported data (33). Participants may forget, misunderstand, or otherwise unintentionally misreport retrospective information such as current levels of physical activity, fruit and vegetable consumption, weight, and the exact nature of the physician's advice. Therefore, research investigating the difference between actual and perceived counseling is needed. However, even if reality and perceptions do not match, it remains important to understand patients' perceptions of health care provider advice, as perceptions are likely to be most influential in affecting a patient's decision to change. Another limitation to this study is that we did not ask participants whether they were counseled for dietary behaviors other than fruit and vegetable consumption. It is possible that participants were told by their health care providers to reduce dietary fat, reduce sugar, or increase fiber. Thus, future research may ask participants whether their health care providers told them to change their eating habits and then follow up by asking them what changes the provider asked them to make.

This study has improved upon this area of research by 1) focusing on individuals who did not meet current recommendations for the behavior of interest, 2) surveying a large African American population, and 3) assessing the relationship between health care provider advice and patients' readiness for change. We found that the rates of health care provider advice for moderate to vigorous physical activity, fruit and vegetable consumption, and weight continue to fall short of the goals set by Healthy People 2010. We also found that provider advice is not based on patients' behaviors but on comorbidities associated with the absence of these behaviors, thus substantiating previous research indicating that individuals who are the least healthy (e.g., high BMI, diagnosed with chronic health conditions) are most likely to be advised by health care providers to change their behaviors. Furthermore, our results indicate that health care provider advice is associated with readiness to change, and it is likely that this (predisease) advice would have been taken into account by patients. Thus, because of the preventive benefit of physical activity, fruit and vegetable consumption, and healthy weight, health care providers are urged to increase counseling for all patients (i.e., healthy and chronically ill). Further research is warranted for the overall effect of provider counseling as well as the identification of moderators (i.e., sex) and mediators for the effect of provider counseling on behavior change.