Adults with cardiovascular disease (CVD) risk factors are candidates for behavioral counseling interventions to promote a healthy diet and physical activity, according to the U.S. Preventive Services Task Force (USPSTF).
The update to a 2014 recommendation explains that it “applies to adults 18 years or older with known hypertension or elevated blood pressure, those with dyslipidemia, or those who have mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater,” wrote Alex H. Krist, MD, MPH, of Virginia Commonwealth University in Richmond, and co-authors in JAMA.
However, the “B” (“moderate net benefit”) grade recommendation “is not specifically targeted for adults with diabetes, obesity, or those who smoke,” as those populations are covered in other USPSTF guidelines, noted Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, in a JAMA Patient Page.
But the recommendation is still “broadly relevant as this represents at least one-third of adults in the general population in the U.S.,” stated Philip Greenland, MD, and Sadiya S. Khan, MD, MSc, both of Northwestern University Feinberg School of Medicine in Chicago, in an accompanying editorial.
In general, “Higher or better cardiovascular health has been associated with both lower risk of CVD, dementia, mortality, and numerous other health-related outcomes,” they explained.
Yet putting out recommendations and seeing them put into practice are separate issues, Greenland and Khan cautioned. For instance, who is best suited to deliver behavioral counseling, given different levels of training, expertise, time, and financial considerations among healthcare professionals?
Krist’s group outlined steps clinicians can follow to implement the recommendation:
- Assessing if the patient has a single or multiple risk factors, possibly with a tool such as the Pooled Cohort Equations or the Framingham Risk Score.
- Providing behavioral interventions that can include individual or group counseling with a median of 12 contacts, with an estimated 6 hours of contact over 12 months; motivational interviewing; goal setting; referring to outside sources or media-based interventions; referring to non-physician specialist such as personal trainers and lifestyle coaches.
Greenland and Khan also asked what type of research is needed to make these recommendations “culturally salient,” such as was done with the SAHELI study in South Asians, and account for social determinants of health? And, what about the use of device-based and mobile health interventions?
The task force acknowledged that “there are large disparities in access to resources that support a healthy diet and increased physical activity,” so the recommendation includes links to resources, called “The Community Guide,” to address these issues.
As for device-based interventions, Krist’s group conceded that “There were limited studies on telemedicine-based interventions and wearable technology. The USPSTF calls for more research in these areas.”
Finally, “national health policies targeting sugar-sweetened [beverages], saturated fats, and tobacco and e-cigarettes should be studied to complement individual-level behavioral counseling,” Greenland and Khan stated. On that front, some states and countries have implemented a “sugar tax” on sugar-sweetened soft drinks, while the FDA as put in some restrictions on e-cigarettes, and food manufacturers have replaced with trans fatty acids with “good fats.”
“Future research is needed on how to personalize health behavior interventions at the individual level in conjunction with population-based interventions to equitably reduce premature mortality,” Greenland and Khan concluded.
Other areas Krist and co-authors would like to see addressed in future research are more consistent and standardized reporting of behavioral outcomes; larger studies with longer-term follow-up; and more replication studies.
The recommendation is based on an evidence report by Elizabeth O’Connor, PhD, of Kaiser Permanente Northwest in Portland, Oregon, and co-authors, who looked at English-only randomized clinical trials (RCTs) of behavioral counseling interventions to help people with elevated blood pressure or lipid levels improve their diet and increase physical activity.
They ultimately evaluated 94 RCTs (n=52,174 participants) with behavioral counseling interventions that involved a median of 6 contact hours and 12 sessions over the course of 12 months. The interventions varied in format and dietary recommendations, with only 5% addressing physical activity alone.
O’Connor and co-authors reported that “pooled analyses of continuous physical activity outcomes did not show statistically significant association, with high statistical heterogeneity” for a pooled standardized mean difference of 0.06 (95% CI −0.03 to 0.14, I2=64%).
They did find that interventions were linked with a lower risk of CV events (pooled relative risk 0.80, 95% CI 0.73-0.87, I2=0%), while event rates were variable. In the large PREDIMED trial, 3.6% in the intervention groups experienced a CV event versus 4.4% in the control group.
As for behavioral counseling interventions — most of which did not involve primary care physicians — they “were associated with small, statistically significant reductions in continuous measures of blood pressure, low-density lipoprotein cholesterol levels, fasting glucose levels, and adiposity at 12 to 24 months’ follow-up,” they wrote, adding that the most beneficial interventions seemed to be motivational interviewing, goal setting, active self-monitoring, and “addressing barriers related to diet, physical activity, or weight change.”
No harms of interventions were reported, and adverse events were rare, although some study participants reported “mild musculoskeletal injuries,” Krist and co-authors noted.
O’Connor’s group pointed out that many of reviewed interventions aimed for weight loss, but “some within-study comparisons suggested that CVD risk reduction can occur in the absence of weight loss… observational evidence also supports the benefits of a healthy diet and physical activity for people with excess weight, even in the absence of weight loss,” as was seen in The Nurses’ Health Study and the Health Professionals Follow-up Study.
The recommendation is in line with multiple guidelines from professional societies, including the American Heart Association/American College of Cardiology, the American Association of Clinical Endocrinologists/American College of Endocrinology, the Academy of Nutrition and Dietetics, and the American Academy of Family Physicians.
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The U.S. Preventive Services Task Force supports offering or referring adults with cardiovascular (CV) disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
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This update to the USPSTF 2014 recommendation does not include adults with impaired glucose tolerance or type 2 diabetes, and does not apply to adults with other known modifiable CV risk factors such as obesity and smoking.
Shalmali Pal, Contributing Writer, BreakingMED™
The USPSTF is funded by the Agency for Healthcare Research and Quality (AHRQ).
All USPSTF members reported receiving travel reimbursement and an honorarium for participating in USPSTF meetings. One member reported relationships with Healthwise.
Greenland reported support from the American Heart Association (AHA) and the NIH, as well as serving as JAMA senior editor. Khan reported support from the AHA.
The evidence report was funded by AHRQ and the U.S. Department of Health and Human Services.
O’Connor and co-authors, as well as Jin, reported no relationships relevant to the contents of this paper to disclose.
Cat ID: 914
Topic ID: 74,914,914,48,94,925
