USPSTF: Individualize behavioral counseling for CVD prevention

The decision to offer or refer adults without cardiovascular risk factors to behavioral counseling to promote a healthful diet and physical activity should be individualized, the U.S. Preventive Services Task Force recommended.

“Despite evidence that healthful dietary patterns, physical activity and limited sedentary time are associated with reduced cardiovascular morbidity and mortality, most U.S. adults are not meeting national recommendations for these behaviors,” Carrie D. Patnode, PhD, from Kaiser Permanente Northwest, and colleagues wrote in the U.S. Preventive Services Task Force (USPSTF) evidence report. “Counseling within primary care and interventions referred through primary care may be one strategy to improve these behaviors and subsequently prevent poor cardiovascular outcomes.”

The USPSTF based its C-grade recommendation on a systematic evidence review of 88 studies (n = 121,190) published between Jan. 1, 2013 and May 25, 2016 that investigated the effects of behavioral interventions aimed to improve diet, increase physical activity and/or decrease sedentary time among adults without obesity or known hypertension, dyslipidemia, diabetes or impaired fasting glucose.

Overall, the Task Force found the interventions did not demonstrate consistent benefit on all-cause or cardiovascular (CV) mortality or morbidity, as well as health-related quality of life. At six to 12 months, there were associations between healthful diet, physical activity interventions or both and small, but statistically significant, improvements in systolic blood pressure (between group mean difference: 1.26 mmHg [95%CI, 1.77 to 0.75]), diastolic blood pressure (mean difference: 0.49 mmHg [95% CI, 0.82 to 0.16]), low-density lipoprotein cholesterol level (mean difference: 2.58 mg/dL [95% CI, 4.30 to 0.85]), total cholesterol level (mean difference: 2.85 mg/dL [95% CI, 4.95 to 0.75]) and BMI (mean difference: 0.41 kg/m² [95% CI, 0.62 to 0.19]). In addition, the task force identified small-to-modest associations with physical activity and dietary behaviors. Serious adverse events, injuries or falls were not more likely in intervention than control participants.

“The Task Force encourages primary care clinicians to talk to their patients about eating healthy and physical activity, and if they are interested and motivated to make lifestyle changes, offer and refer them to counseling,” Susan Curry, PhD, vice chair of the Task Force, said in a related press release.

Behavioral counseling interventions include educational sessions, individualized care plans, problem-solving skills and feedback that aims to encourage participants to improve their diet, increase exercise and limit unhealthy behaviors, according to the USPSTF. These programs are often conducted face-to-face and/or via telephone inside or outside of a doctor’s office over several months, according to the Task Force.

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“Diet and physical activity behavioral interventions for adults not at high risk for cardiovascular disease result in consistent modest benefits across a variety of important intermediate health outcomes across 6 to 12 months, including blood pressure, low-density lipoprotein and total cholesterol levels, and adiposity, with evidence of a dose response effect, with higher-intensity interventions conferring greater improvements,” Patnode and colleagues concluded. “There is very limited evidence on longer-term intermediate and health outcomes or on harmful effects of these interventions.”

In a separate recommendation, the USPSTF advises that all high-risk patients, including individuals who are obese or overweight and have other known risk factors for CVD undergo, behavioral counseling.

In a related editorial, Philip Greenland, MD, from the Northwestern University Feinberg School of Medicine, and Valentin Fuster, MD, PhD, from the Icahn School of Medicine at Mount Sinai, highlighted the importance of controlling CVD risk factors.

“Several lessons from this guideline and associated literature review deserve wider recognition,” they wrote. “First, the evidence is strong, consistent and persuasive that CVD risk factor prevention and treatment are associated with lower rates of CVD.”

“Second, the guideline addresses the challenges that remain in treating and controlling risk factors in the clinical setting,” Greenland and Fuster added. “Nonetheless, risk factor control in the clinical setting begins with risk assessment, aims at targeting all risk factors above ideal levels and moves patients in measured steps toward more ideal cardiovascular health... Better methods of treating CVD risk are needed, and these are complementary to the need for population-wide public health approaches directed at everyone.” – by Alaina Tedesco

References:

Greenland P. Fuster V. JAMA. 2017;doi:10.1001/jama.2017.7648.

Patnode CD, et al. JAMA. 2017;doi:10.1001/jama.2017.3303.

USPSTF. JAMA. 2017;doi:10.1001/jama.2017.7171.

Disclosures: The USPSTF reports support from the Agency for Healthcare Research and Quality. Greenland and Fuster report no relevant financial disclosures.