Summary
Background
One of the major issues in controlling serum cholesterol through dietetic intervention appears to be the need to improve patient adherence.
Aims
To explore the many questions regarding barriers to, and motivators for, cholesterol-lowering diet adherence.
Methods
We surveyed French general practitioners’ dietetic practices for patients with hypercholesterolaemia, and looked at their patients’ attitudes towards such an approach.
Results
We analysed 234 doctors’ personal questionnaires and 356 patient self-survey questionnaires. Patients’ reasons for not complying with the prescribed diet included: ‘already having satisfactory food habits’ (34.7%), ‘unwillingness to suffer nutritional deprivation’ (33.3%), ‘difficulties to conciliate a diet with family life’ (27.8%) and ‘taking cholesterol-lowering drugs’ (22.2%). Despite a generally good understanding by patients of doctors’ recommendations, some discrepancies were seen between their respective declarations. While doctors largely thought that patients needed more explanation on why and how a diet can lower cholesterol (and avoid taking drugs), only 39.4% of patients declared needing this kind of information. Other discrepancies were observed concerning barriers to, and motivators for, patient adherence. Moreover, some dietetic rules appeared to be more difficult to comply with than others, e.g. 82.6% patients remembered they should ‘eat more fish’ but only 51.3% actually did so. Finally, physicians, as well as patients, displayed a lack of confidence in lipid-lowering diet efficiency.
Conclusion
Improving patient education, especially concerning their perception of risk, as well as increasing the involvement of dieticians, are motivators to explore in order to improve adherence.
Résumé
Contexte
L’amélioration de l’observance et le respect des prescriptions diététiques par les patients sont des problématiques majeures dans le suivi des régimes hypocholestérolémiants.
Objectif
Explorer les nombreuses questions relatives aux freins et aux leviers agissant sur l’observance des régimes hypocholestérolémiants.
Méthodes
L’étude a observé les pratiques des médecins généralistes français auprès de leurs patients hypercholestérolémiques et les attitudes de ces derniers vis-à-vis de la prescription.
Résultats
Deux-cent-trente-quatre questionnaires personnels des médecins et 356 auto-questionnaires des patients ont été analysés. Les premières réponses invoquées par les patients (traités ou non traités) sur les raisons de leur non-observance du régime prescrit étaient : « ayant déjà des habitudes alimentaires satisfaisantes » (34,7 % des interrogés), réticence aux privations (33,3 %), difficultés à concilier le régime avec une vie familiale (27,8 %) et prise de médicaments hypocholestérolémiants (22,2 %). Malgré la bonne compréhension générale des patients vis-à-vis des recommandations des médecins, des divergences ont été observées entre leurs déclarations respectives : alors que la plupart des médecins pensaient que les patients avaient besoin davantage d’explications sur pourquoi et comment un régime peut faire baisser le cholestérol (et éviter le traitement médical), seuls 39,4 % des patients déclaraient en avoir besoin. D’autres divergences ont été constatées au sujet des freins et des leviers agissant sur l’observance. Par ailleurs, certaines règles diététiques semblent plus difficiles à respecter que d’autres : par exemple, 82,6 % des patients se rappellent devoir « manger plus de poisson » mais seulement 51,3 % le mettent en pratique. Enfin, les médecins tout comme les patients montrent un manque de confiance dans l’efficacité des régimes hypolipidémiants.
Conclusions
L’amélioration de l’éducation des patients, notamment sur la perception des risques, mais également le renforcement de l’implication des diététiciens, sont des leviers à explorer pour améliorer l’observance.
Background
Decreasing low-density lipoprotein cholesterol (LDL-c) to an adequate target level can significantly reduce the risk of suffering a first coronary event . Even a small decrease in total cholesterol may prevent a large number of such events. Indeed, a large study conducted in the US demonstrated that a major decrease (44%) in deaths from coronary heart disease (CHD) was attributable to changes in risk factors, including a 24% decrease due to a 6% reduction in total cholesterol .
A broad base of evidence supports recommendations for lifestyle changes for LDL-c-lowering therapy in primary prevention . A more recent study has also confirmed that dietary interventions actually reduce risk factors for cardiovascular disease (CVD) and can be implemented in practice . Among the therapeutic lifestyle changes aimed at reducing the risk of CHD, reduced intakes of saturated fats and cholesterol, as well as other therapeutic dietary options for lowering LDL-c (plant stanols/sterols and increased viscous fibre), are recommended to reach the LDL-c objective .
Hence, in hypercholesterolaemic patients, the goal of reducing cholesterol and improving risk factors can be achieved by improving food habits even slightly. However, patient adherence to dietary recommendations, which is essential to ‘make it work’, is difficult to achieve. Despite some recent improvements in knowledge about cholesterol, patient adherence to cholesterol treatment recommendations remains sub-optimal . Numerous studies have addressed this issue specifically . Others have tried to intervene upstream by understanding barriers to adherence, which can be multiple and vary from person to person . Barriers relate to patients as well as to doctors , placing the doctor–patient relationship at the core of the problem, and its solution.
However, various questions remain unanswered. Is the doctor’s perception of patient adherence accurate? What are the obstacles to/motivators for cholesterol-lowering diet adherence? What are the motivators for improving cholesterol-lowering dietary recommendations? To help answer these questions, the present study surveyed French general practitioners for their dietetic practices for patients with hypercholesterolaemia, and their patients’ attitude towards such recommendations.
Methods
Study design and participants
In this multicentre, prospective, observational study, hypercholesterolaemic patients were recruited by a representative sample of general practitioners in France.
General practitioners were recruited randomly from the Danone Santé database by an independent company. Within a 1-month period, each practitioner had to include two hypercholesterolaemic adult (≥ 18 years) patients; one had to be on a cholesterol-lowering medication and one had to be medically untreated.
Both patients had to have been diagnosed 1 to 6 months beforehand with hypercholesterolaemia (LDL-c > 4.1 mmol/L). Patients were excluded if they: were participating in another clinical trial; presented with coronary heart disease, cerebrovascular disease or symptomatic peripheral vascular disease; or were following an atypical diet.
Questionnaires
A series of questions was developed following several 3-hour focus group sessions, involving a total of eight general practitioners and 24 patients, recruited from two and three French regions, respectively. Three questionnaires were developed ( Appendix A ):
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the doctors’ personal questionnaire concerned personal data (gender, age, thesis date, geographical region of practice, proportion of patients with cardiovascular risk factors, difficulties encountered when prescribing a diet and opinion on principles facilitating patient adherence [0–10 scales]);
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the doctors’ questionnaire on the patient concerned social and demographic data, date of diagnosis, family history of coronary heart disease, cardiovascular risks, biological data at hypercholesterolaemia diagnosis (serum cholesterol and triglycerides, cholesterol-lowering treatment, cholesterol-lowering diet, opinion on importance of compliance with diet and other recommendations [physical activity, stopping smoking, etc.]). This questionnaire was filled in by the doctor during the consultation;
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the patient self-survey questionnaire concerned personal data (age, gender, serum cholesterol figures, cholesterol-lowering medication, opinion on importance of compliance with diet for their health, current food habits, cholesterol-lowering diet, need for complementary information or specific aids to comply with the diet, opinion on importance of compliance with diet for lowering cholesterol, other recommendations from doctor and relative importance attached to various recommendations to fight cholesterol). The patient had to fill in the questionnaire at home, alone and without help from the doctor.
Objective
The primary objective was to assess actual dietetic care modalities and patient adherence for medically treated and untreated hypercholesterolaemic patients in general practice.
Sample size
To reach the primary objective, the principal criterion was the proportion of subjects presenting an adequate diet (defined beforehand by the Scientific Committee according to a benchmark calculated on the basis of food habits described in the patients’ self-survey questionnaire). Because of lacking data, the hypothesis was that this proportion would reach 50% of subjects. To estimate the actual proportion in medically treated and untreated groups with a 95% confidence interval and a 5 to 10% absolute precision for the whole sample, 267 subjects were needed in each group (medically treated and untreated).
Statistical analysis
Multi-variable analysis was performed based on data collected from the practitioners’ declarative questionnaires assessing their level of compliance, on a scale from 0 to 10, regarding different opinions related to dietary recommendations (barriers and motivators).
Principal component analysis (PCA) was performed to determine links between the studied variables, the existence of correlated groups of variables, and to highlight variables that would characterize different homogeneous groups. Several PCAs were performed, first on the raw marks (0–10) given to the studied variables, then on the standardized marks,
Then, hierarchical ascendant classifications (HAC) were performed based on the first three factors resulting from the PCA. The objective was to split practitioners into subgroups, each one characterized by homogeneous behaviour regarding dietary recommendations (practitioners’ typology).
All analyses were performed with SPSS Version 11.0.
Results
Patient population
A total of 488 hypercholesterolaemic patients were recruited by 239 general practitioners in France between 2nd April and 15th May 2006. Only 236 physicians included two patients, as specified in the study protocol. A total of 488 patients were included in the study, of whom 475 had an available inclusion questionnaire, and 434 were selected (all inclusion criteria met) for descriptive analysis of the inclusion phase. Patient characteristics at inclusion are shown in Table 1 . Among these patients, 356 had both analysable inclusion questionnaires (filled in by the doctors) and self-survey questionnaires, and were selected for further descriptive analysis.
| Treated ( n = 226) | Untreated ( n = 208) | p | |
|---|---|---|---|
| Men | 65.5 | 51.9 | 0.004 |
| Age (years) | 57.8 | 53.9 | 0.03 |
| Marital status | |||
| Single | 10.2 | 9.6 | 0.21 |
| Married | 72.4 | 67.8 | 0.21 |
| Divorced or separated | 3.6 | 9.1 | 0.21 |
| Weight (kg) | 80.8 | 74.9 | < 0.001 |
| BMI (kg/m 2 ) | 27.8 | 26.3 | 0.002 |
| Duration of hypercholesterolaemia (weeks) | 17.2 | 13.1 | < 0.001 |
| Family history of early coronary heart disease | 24.8 | 13.9 | 0.004 |
| Personal risk factor(s) for cardiovascular disease | |||
| ≥ 1 | 84.5 | 65.9 | < 0.001 |
| ≥ 2 | 69.1 | 42.3 | < 0.05 |
Dietary recommendations and patient adherence
When asked ‘Did you recommend a cholesterol-lowering diet to this patient?’, doctors answered positively for 97.2% of their patients. Similarly, when asked ‘Did your doctor recommend a cholesterol-lowering diet?’, 98.2% of patients answered positively.
Doctors explained the diet once at the beginning more often in medically untreated patients (62.3% vs. 47.3%; P = 0.002), but gave dietetic advice regularly during successive medical visits more often in medically treated patients (60.9% vs. 46.2%; P = 0.003) ( Table 2 ).
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