In a draft recommendation statement(www.uspreventiveservicestaskforce.org) issued Nov. 29, the U.S. Preventive Services Task Force (USPSTF) essentially reiterated its 2012 recommendation that physicians who care for adults at low or average risk for cardiovascular disease (CVD) should consider offering or referring them to behavioral counseling to promote a healthy diet and regular physical activity to prevent CVD.
This "C" recommendation(www.uspreventiveservicestaskforce.org) applies to individuals without obesity (i.e., those who are normal weight or overweight, with a body mass index between 18.5 and 30 kg/m2) who are age 18 or older and have no known CVD risk factors such as hypertension, dyslipidemia, diabetes or abnormal blood glucose.
Although no doubt exists that CVD is the nation's leading cause of death,(www.cdc.gov) and it is widely acknowledged that adults who consume a healthy diet and are physically active lower their risk for CVD-related events, "existing evidence indicates that the health benefit of behavioral counseling to promote a healthful diet and physical activity among adults without obesity who do not have these specific CVD risk factors is small," says the draft statement.
It should be noted that a separate recommendation statement(www.uspreventiveservicestaskforce.org) the task force released in 2014 pertains to adults who do have these risk factors, calling for them to be offered or referred to "intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention" -- a "B" recommendation.
- A draft recommendation from the U.S. Preventive Services Task Force calls for physicians to consider offering or referring adults at low or average risk for cardiovascular disease (CVD) to behavioral counseling to promote a healthy diet and regular physical activity to prevent CVD.
- This "C" recommendation applies to individuals with a body mass index between 18.5 and 30 kg/m2 who are age 18 or older and have no known CVD risk factors.
- One family physician expert notes that most FPs already talk with their patients about healthy behaviors, and although there may be more emphasis on doing so with patients who have CVD risk factors, it's still important and appropriate for all individuals.
Review of the Evidence
According to a draft evidence review(www.uspreventiveservicestaskforce.org) also released Nov. 29, task force members based their current recommendation on findings from 88 clinical trials -- 50 of which they had reviewed when considering their 2012 recommendation, plus 38 new studies.
Of the dozen of these trials that reported patient-oriented health outcomes (e.g., CVD events, self-reported quality of life), four that involved high-intensity diet-only interventions (all of which were included in the previous review) found no difference in all-cause or CVD-related mortality between the study and control groups during three to 15 years' follow-up. In addition, findings involving CVD events over eight to 15 years' follow-up were inconsistent.
Results from 10 trials that focused primarily on physical activity showed general improvements among intervention participants in quality-of-life scores over six to 12 months, but no consistent intervention benefit was seen compared with controls.
Among the 34 studies that examined intermediate outcomes, small but statistically significant improvements were seen in both systolic and diastolic blood pressure levels, as well as in LDL and total cholesterol readings. Investigators with the Kaiser Permanente Research Affiliates Evidence-based Practice Center, which prepared the review, also noted gains in some adiposity outcomes but urged caution when interpreting pooled results in this area because of "considerable statistical heterogeneity in all of these analyses."
No evidence pointed to associations with HDL cholesterol, triglycerides or fasting glucose levels, and only limited evidence was seen regarding the effects of interventions on incident hypertension, dyslipidemia and diabetes. And although there was some evidence of a "dose-response" effect -- with more intensive interventions being associated with more pronounced improvements in intermediate outcomes -- evidence was lacking to assess the effects of lower-intensity interventions alone.
Regarding behavioral outcomes, the researchers found consistent evidence showing that behavioral interventions, in general, improved participants' dietary intake and physical activity levels at six to 12 months of follow-up, although no dose-response effect of intervention intensity was observed.
No serious adverse effects associated with counseling were identified, and there was no difference in the relative incidences of injuries, falls or adverse CVD events between physical activity intervention and control groups.
Translation to Practice
As for implementing this guidance in the exam room, Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that in many cases, these conversations are already taking place.
"Most family physicians talk with their patients about healthy behaviors," Frost explained. "We certainly give it more emphasis with patients who have risk factors for cardiovascular disease, but it is still important and appropriate for all individuals."
After all, she noted, "Adults without any risk factors for cardiovascular disease are not common in most practices. But for those patients, behavioral changes may help prevent them from developing risk factors.
"We should also remember that there are likely many more benefits to healthy diet and physical activity beyond cardiovascular effects, such as improvements in mood, energy level and concentration."
Frost acknowledged the fact that real-world considerations have to be taken into account when deciding when and how to focus efforts in this area. "With the limitations in time and resources, physicians may reserve more intensive behavioral counseling for those individuals without risk factors who are motivated to make substantial behavioral change."
That last factor is particularly important to achieving a successful outcome, she added.
"It is essential that the patient is motivated to make these changes, or the counseling is a waste of time.
"Determining what changes the individual is willing and able to make and focusing on small changes can help encourage the patient to embrace healthier behaviors."
It's important to keep in mind that because this is not an "A" or "B" recommendation, "insurers are not obligated to cover this service, particularly referral for intensive counseling," Frost advised. "Low intensity counseling, however, is covered as part of a wellness visit."
What's Up Next
The USPSTF is inviting comments on both the draft recommendation statement(www.uspreventiveservicestaskforce.org) and the draft evidence review(www.uspreventiveservicestaskforce.org) until 8 p.m. EST on Jan. 2. Those comments will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will release its own recommendation on this topic after the task force finalizes its guidance.
Related AAFP News Coverage
USPSTF: Screen Children, Adolescents for Obesity
Task Force Recommends Behavioral Interventions as Needed