USPSTF: Individualize behavioral counseling decisions for adults without CVD risk factors

The U.S. Preventive Services Task Force issued a final statement recommending clinicians individualize the decision to offer behavioral counseling to adults with no CVD risk factors that will promote physical activity and a healthy diet.

Alhough there is limited evidence on the long-term effects of behavioral counseling, Carrie D. Patnode, PhD, MPH, a behavioral epidemiologist at the Kaiser Permanente Evidence-based Practice Center, and colleagues wrote in an evidence report that it is associated with “small but statistically significant benefits across a variety of important intermediate health outcomes” in adults without known CVD risk factors.

The recommendation statement, which closely aligns with the USPSTF’s draft recommendation that was released in January, notes the urgency of the situation. By 2035, about half of adults in the U.S. are anticipated to have some form of CVD — the leading cause of death in the U.S., the task force wrote.

“Adults who adhere to national guidelines for a healthy diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not; however, many U.S. adults do not consume healthy diets or engage in physical activity at recommended levels,” they wrote.

Previous research has shown that 150 minutes of physical activity each week cuts the risk for death, and that it does not particularly matter how the exercise is spread throughout the week.

The USPSTF commissioned an evidence review to update its 2017 “C” grade guidance, which offered similar recommendations and was backed by the American Academy of Family Physicians. The current review included 113 randomized clinical trials including 129,993 people from a variety of demographics. The USPSTF said it found “sufficient evidence” that behavioral counseling interventions led to modest increases in physical activity levels and some improvements in dietary behaviors.

In a related editorial, Dariush Mozaffarian, MD, DrPH, Jean Mayer Professor of Nutrition and a professor of medicine at Tufts School of Medicine and in the division of cardiology at Tufts Medical Center, noted that the new recommendation statement applies to a minority of adults in the U.S. — those without CVD risk factors such as hypertension, dyslipidemia, impaired glycemia, metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater.

“While this group might seem representative of the general population, lifestyle-related conditions such as high blood pressure, high cholesterol levels and prediabetes are so common among U.S. adults that the group to whom the USPSTF recommendations apply represents a very small proportion of the U.S. adult population: only an estimated 12.2%,” Mozaffarian wrote.

For the majority of U.S. adults, “clinicians should provide or refer them to intensive behavioral counseling,” he wrote. However, nationally, only about 25% of patients with diabetes and 15% of other patients currently receive diet or exercise counseling, according to Mozaffarian.

There are many barriers to implementation, Mozaffarian wrote, including insufficient clinician education, the absence of efficient lifestyle screening and tracking tools in electronic health records, inadequate referral systems and services to improve diet and exercise, and “limited payer reimbursement, incentives and quality-of care standards for addressing lifestyle.”

While some health systems are beginning to launch food-based interventions and physical activity screening, “much remains to be done,” Mozaffarian wrote.

“Further health systems innovations can incorporate and prioritize action on diet and physical activity, including improved clinician education, health record screening and tracking, evidence-based behavioral counseling, referrals to appropriate services, and corresponding reimbursement and quality-of-care standards,” Mozaffarian wrote. “These actions could help increase the provision of and referral to intensive behavioral counseling to improve diet quality and physical activity.”

References:

Patnode CD, et al. JAMA. 2022;doi:10.1001/jama.2022.7408.

Mozaffarian D. JAMA. 2022;doi:10.1001/jama.2022.10801.

USPSTF. JAMA. 2022;doi:10.1001/jama.2022.10951.