POPULATIONS AT RISK
Receipt of Nutrition and Exercise Counseling Among Medical
Outpatients with Psychiatric and Substance Use Disorders
Mayur M. Desai, PhD, MPH, Robert A. Rosenheck, MD, Benjamin G. Druss, MD, MPH,
Jonathan B. Perlin, MD, PhD
OBJECTIVE: Mentally ill persons represent a population that is
potentially vulnerable to receiving a poorer quality of medical
care. This study examines the relationship between mental
disorders and the likelihood of receiving recommended
nutrition and exercise counseling.
DESIGN: Cross-sectional study combining chart-review data
and administrative database records.
SETTING: One hundred forty-seven Veterans Affairs (VA)
medical centers nationwide.
patients with obesity and/or hypertension who had 3
medical outpatient visits in the previous year.
MEASUREMENTS AND MAIN RESULTS: The outcomes of
interest were chart-documented receipt of nutrition
counseling and receipt of exercise counseling in the past 2
years. This chart information was merged with VAinpatient
and outpatient administrative databases, which were used to
identify persons with diagnosed mental disorders. Most
patients received nutrition counseling (90.4%), exercise
counseling (88.5%), and counseling for both (85.7%) in the
past 2 years. The rates of counseling differed significantly but
modestly by mental health status. The lowest rates were found
among patients dually diagnosed with comorbid psychiatric
and substance use disorders; however, the magnitude of the
disparities was small, ranging from 2% to 4% across outcomes.
These results were unchanged after controlling for demo-
graphics, health status, and facility characteristics using
multivariable generalized estimating equation modeling.
CONCLUSIONS: Among patients engaged in active medical
treatment, rates of nutrition and exercise counseling were
high at VAmedical centers, and the diagnosis of mental illness
was not a substantial barrier to such counseling. More work is
needed to determine whether these findings generalize to non-
VAsettings and to understand the potential role that
integrated systems such as the VAcan play in reducing
disparities for vulnerable populations.
KEY WORDS: mental disorders; nutrition; exercise; counseling;
J GEN INTERN MED 2002;17:556±560.
oor diet and physical inactivity are well-established risk
factors for chronic disease morbidity and mortality.
Studies suggest that counseling by primary care providers
can play an important role in helping to bring about
positive changes in patients' health behaviors.
Preventive Services Task Force recommends that clinicians
counsel their patients regarding the role of proper nutrition
and exercise in achieving and maintaining good health.
Despite these recommendations, however, studies indicate
that a substantial proportion of patients do not receive
It is important to identify
subgroups of patients who may be less likely to receive
nutrition and exercise counseling, so that efforts to
increase rates of counseling may be appropriately targeted.
Compared with the general population, patients with
mental disorders have poorer health behaviors, including
worse diet and lower rate of physical activity.
the use of antipsychotics
been associated with substantial weight gain. Thus, people
with mental illness represent a patient population for
whom nutrition and exercise counseling may be particu-
larly important. However, research suggests that mentally
ill patients are potentially vulnerable to receiving a poorer
quality of medical care than persons with no mental
and generalists may have difficulty in
addressing the medical needs of patients with substance
use disorders in particular.
This may be especially
problematic with respect to counseling, which relies on
effective patient-physician communication,
cognitive, affective, and behavioral symptoms associated
with mental illness may hinder such communication.
To date, no empirical studies have examined the
association between mental disorders and the likelihood
of receiving nutrition and exercise counseling. In the
present study, we examined this relationship in a large
national sample of medical outpatients receiving care at
Received from the Mental Illness Research, Education, and
Clinical Center, VA Connecticut Healthcare System (MMD, RAR,
BGD), West Haven, Conn; the Department of Psychiatry, Yale
University School of Medicine (MMD, RAR, BGD), New Haven,
Conn; and the Office of Quality and Performance, Department of
Veterans Affairs (JBP), Washington, D.C.
Address correspondence and requests for reprints to Dr.
Desai: VA Connecticut Healthcare System, 950 Campbell Ave.
NEPEC (182), West Haven, CT 06516 (e-mail: mayur.desai@