The present study showed that, in hypertension-related GP visits, lifestyle counseling was performed in 40% of the observed visits. An assessment of lifestyle was performed in one third of the visits, most commonly for weight and nutrition, and less frequently for smoking and physical activity. In one sixth of the visits a recommendation to change behavior was made. Most of the advice regarded nutrition. The discussion of nutrition was most often initiated by the patient whereas the discussion of weight and smoking was most often initiated by the GP.
In most visits the duration of lifestyle counseling was brief, in only 7% of the visits it took more than a quarter of the visits. In addition, observation of the videotaped visits revealed that specific elements of lifestyle counseling were rarely or never used by the GPs. For example, the patient's motivation for a change in behavior and potential barriers or supporting factors were almost never discussed, and in none of the visits a follow-up visit for the evaluation of the behavior change was planned. This illustrates that the lifestyle advice was almost never specified and tailored to the specific situation of the patient. Thus, in most visits the discussion of lifestyle can actually not be characterized as lifestyle counseling in the strictest sense, but rather as a brief lifestyle advice (and/or assessment).
The frequency of lifestyle counseling in this study was lower than that reported in previous studies [17–19] However, in these studies the frequency of lifestyle counseling was determined using GP questionnaires, and thus GPs may have overestimated the frequency of lifestyle advice. In addition, in some of these studies response rates were low [17, 18] which may have lead to selection bias. Another reason that the frequency of lifestyle counseling in our study is lower than that in previous studies may be that we have included only one visit per patient. According to the guidelines patients with hypertension have to visit their GP at least two times per year . In previous studies it was assessed whether the GP gave lifestyle advice during the first hypertension-related visit [18, 19] or at any given time .
Using video recordings of real life, everyday visits, we were able to determine what GPs actually do in practice. In this study the response rate was relatively high, 73% of the GPs and 88% of the patients agreed to have the visit recorded . The study was primarily aimed at the communication between GPs and patients. So, both patients and GPs were not aware that lifestyle counseling would be one of the topics of investigation. Therefore it is not likely that GPs and/or patients have changed the frequency of lifestyle counseling because the visit was recorded on video.
A drawback of this study is that the current lifestyle of the patients was not known. For instance, it was not known whether the patient was a smoker or was overweight, unless this was mentioned during the visit. The GP can make an assessment of the patient's weight by looking at the patients, and may have knowledge about the lifestyle of the patient from previous visits. In addition, in the Second Dutch Survey of General Practice, the majority of the practice assistants indicated that they (sometimes) perform blood pressure measurements . This may also be an opportunity for lifestyle counseling, but these patient contacts have not been included in the video recordings.
It is likely that the results may cluster per GP, and thus this should preferably be taken into account during the analyses, i.e. to perform multi-level analyses. However, for most (73%) of the GPs we included only one or two visits. Therefore, it was not feasible to perform multilevel analysis.
Our study was primarily aimed at the frequency of lifestyle counselling and the way it was delivered in practice. We did not focus on congruence of the actual contents of the assessment and advice with existing guidelines and/or other available evidence, but as mentioned previously most advices were brief and quite general. Due to the study design we could not evaluate whether certain counselling elements (e.g. assessment of the patient's motivation of the change in behaviour, goal-setting etc.) indeed increased the efficacy of the advice. Thus, further research is needed to evaluate the actual content and efficacy of the advice.
In 2001, approximately half of the GP patients was overweight (BMI > 25) . Given the fact that overweight is one of the risk factors contributing to hypertension , we expect the prevalence of overweight in this group of patients to be even higher. According to the guidelines, if applicable, attention should be paid to the modifiable risk factors (smoking, weight and alcohol use) during every visit. However, in only one fifth of the visits an assessment of weight was made, and only nine patients received advice regarding their weight. This indicates that only a small proportion of the eligible patients have received counseling regarding their weight, and that the frequency of lifestyle counseling could be increased. To achieve this, barriers to lifestyle counseling, such as lack of time should be addressed. Since lack of time is one a the main barriers reported by GPs [6–8]., a potential solution may be that lifestyle counseling is (partly) performed by other health professionals, such as practice assistants or nurse physicians.
In this study, men more often received lifestyle advice than women, and this could be mainly contributed to a higher frequency of weight loss advice. This is partly contradicts results of previous research which showed that although men more often received lifestyle advice than women, [26, 27], they were less often encouraged to lose weight [10, 27, 28].
A possible explanation for the higher frequency of lifestyle advice in men may be that GPs particularly target high-risk patients and men may be perceived to be at higher (cardiovascular) risk [26, 27] On the other hand, it has been suggested that women are more likely to ask about lifestyle, particularly diet and weight, which may explain the contradictory results for weight loss advice . In our study weight loss advice was mainly initiated by the GP, and thus it may also be explained by the GPs high-risk approach. As we have mentioned before, we did not have information on patient's weight status. Thus, the higher frequency of weight loss counseling in males may be explained by a higher prevalence of overweight in male than in female patients. However, this is not in line with our expectations, because in 2001 the prevalence of overweight in male primary care patients aged 55–74y was slightly lower than that in female patients .
The assessment of weight and smoking was more often initiated by the GP than the discussion of nutrition and physical activity. This can probably be explained by the fact that weight status and smoking are relatively easy to assess. Thus, probably nutrition and physical activity would be more frequently assessed if tools would become available for routine recording in a standardized way.
In 2006 the guidelines for Hypertension  and Cholesterol  were replaced by the guideline Cardiovascular risk management . The recommended lifestyle advice in this standard are almost identical to those in the hypertension guideline. So we don't expect that the quality and frequency of lifestyle counseling of GPs was changed due to the revision of the guideline(s). However, a significant change compared to the previous (hypertension) guideline is that it is advised to refer motivated patients to a practice assistant, nurse practitioner, physiotherapist, dietician, behavioral counselor, a (stop smoking) course, or self-help program. In addition, it is likely that the attention for lifestyle of both GPs and patients has increased since 2001, because there seems to be a growing interest for this topic in general. The Third National Survey of General Practice that is currently in preparation provides an opportunity to study whether the frequency and quality of lifestyle counseling have changed in recent years.