November 24, 2020
3 min read
All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. One author reports he received grants and personal fees from Healthwise. The authors of the evidence summary report no relevant financial disclosures. Khan reports she received grants from the American Heart Association. Greenland reports he received grants from the AHA and NIH.
In an updated recommendation, the U.S. Preventive Services Task Force stated that medium- and high-intensity counseling for dietary and physical activity behaviors may be beneficial among all adult patients with high BP and/or dyslipidemia.
Alex H. Krist
“This recommendation replaces the 2014 USPSTF recommendation on behavioral counseling to promote a healthy diet and physical activity for CVD prevention in adults with cardiovascular risk factors,” Alex H. Krist, MD, MPH, professor of family medicine and population health at Virginia Commonwealth University, clinician and teacher at the Fairfax Family Practice Residency and chairperson of the USPSTF, and colleagues wrote. “At that time, the USPSTF recommended intensive behavioral counseling interventions for overweight and obese adult patients with known CVD risk factors, including hypertension, dyslipidemia, impaired fasting glucose or glucose intolerance, and metabolic syndrome. The new recommendation targets adults with known hypertension or elevated blood pressure, elevated lipid levels or dyslipidemia, and mixed or multiple risk factors.”
The updated recommendation was published in JAMA alongside an USPSTF evidence report that evaluated 94 randomized controlled trials in behavioral counseling for diet and exercise. The analysis looked at the benefits and harms of counseling among patients with known CV risk factors.
The updated recommendation applies to adults aged at least 18 years with elevated risk for CVD, defined as having hypertension or elevated BP, dyslipidemia or mixed/multiple risk factors such as the metabolic syndrome or an estimated 10-year CVD risk of at least 7.5%.
According to the recommendation statement, this update does not apply to adults with other known modifiable CV risk factors such as abnormal blood glucose levels, obesity and smoking; that population is addressed in other USPSTF recommendations.
Moreover, this recommendation is consistent with the 2014 USPSTF recommendation statement with the exception that it no longer includes adults with impaired glucose tolerance or type 2 diabetes, who are also addressed in a separate USPSTF recommendation.
The USPSTF broke down the application of its updated recommendation into two parts: risk assessment and the provision of behavioral counseling for this population.
To determine a patient’s risk for CVD, the statement recommended:
- Assess whether a single risk factor or multiple risk factors are present (dyslipidemia, elevated BP or hypertension, or multiple or mixed risk factors).
- Use a risk tool such as the Pooled Cohort Equations or the Framingham risk score.
For the implementation of behavioral counseling, the statement recommended the following:
- A combination of counseling on a healthy diet and physical activity, with multiple contacts including either individual or group sessions over extended periods.
- Dietary counseling advice may include reductions in saturated fats, sodium and sweets and greater intake of fruits, vegetables and whole grains.
- Physical activity counseling focuses on patients achieving 90 to 180 minutes per week of moderate to vigorous activity.
- Counseling with a median of 12 contacts, with around 6 hours of contact over a 12-month period.
- One-on-one time with an interventionalist, and motivational interviewing and behavioral change techniques such as goal-setting, self-monitoring and addressing barriers to diet, physical activity or weight change.
- Counseling provided in-person, referred to outside counseling services or from media-based interventions.
- Interventions can be carried out by nonphysicians (nurses, dietitians, nutritionists, exercise specialists, physical therapists, masters- and doctoral-level counselors) trained in behavioral methods.
- Counseling can be supported by family members in addition to the individual with CVD risk factors.
Sadiya S. Khan
“Higher or better cardiovascular health has been associated with both lower risk of CVD, dementia, mortality and numerous other health-related outcomes,” Sadiya S. Khan, MD, MSc, assistant professor of medicine (cardiology) and preventive medicine (epidemiology), and Philip Greenland, MD, Harry W. Dingman Professor of Cardiology, professor of preventive medicine and director of Institute for Public Health and Medicine’s Center for Population Health Sciences at Northwestern University Feinberg School of Medicine, wrote in a related editorial. “In addition, cardiovascular health in women assessed during pregnancy is associated both maternal (preeclampsia) and offspring (weight and insulin sensitivity at birth) outcomes, supporting the importance of comprehensively targeting cardiovascular health earlier in life and beginning in utero to prevent intergenerational transmission of risk. Further, disparities in cardiovascular health persist by race/ethnicity, education, employment and income, and geography.
“The data to support optimizing dietary patterns and physical activity to promote cardiovascular health is robust, rigorous and spans the life course from in utero to older adulthood,” Khan and Greenland wrote. “Yet effective translation of these available data from randomized clinical trials to implementation in clinics, communities and individuals is lacking. Since health behaviors (healthy as well as unhealthy) often cluster together, whereby adults who consume healthier diets also often engage in regular physical activity, a comprehensive approach to cardiovascular health promotion may be best suited to all populations, including adults with or without established risk factors.”