On July 11, the U.S. Preventive Services Task Force (USPSTF) published a final recommendation statement(www.uspreventiveservicestaskforce.org) and evidence summary(www.uspreventiveservicestaskforce.org) reaffirming its draft 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 is a "C" recommendation(www.uspreventiveservicestaskforce.org).
This recommendation, which updates the task force's 2012 recommendation statement, applies to patients 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 adults who consume a healthy diet and are physically active lower their risk for CVD-related events, "intensive behavioral counseling on healthy eating and physical activity may help prevent cardiovascular disease for some people who aren't at increased risk," the task force said.
"Existing evidence indicates a positive, but small, benefit of behavioral counseling for the prevention of CVD in this population," the final recommendation noted. "Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling."
- On July 11, the U.S. Preventive Services Task Force (USPSTF) published a final recommendation statement and evidence summary reaffirming its draft 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 recommendation applies to patients without obesity (i.e., those 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.
- A separate recommendation statement 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."
The AAFP has released its own final recommendation on intensive behavioral counseling for low- to average-risk individuals that mirrors that of the USPSTF.
"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," said USPSTF Vice Chair Susan Curry, Ph.D., in a news release(www.uspreventiveservicestaskforce.org).
Furthermore, said USPSTF member Carol Mangione, M.D., M.S.P.H., in the release, "This recommendation complements separate task force recommendations for people at increased risk(www.uspreventiveservicestaskforce.org), which recommend behavioral counseling for all high-risk patients." The AAFP agrees with this 2014 "B" recommendation, as well.
As noted in previous AAFP News coverage, USPSTF members based their final recommendation on findings from 88 clinical trials -- 50 of which they had reviewed when formulating their 2012 recommendation.
Four trials that reported patient-oriented outcomes, such as CVD events or self-reported quality of life, involved high-intensity, diet-only interventions and found no difference in all-cause or CVD-related mortality between the study and control groups during three to 15 years' follow-up. Moreover, findings that involved CVD events over eight to 15 years of follow-up were inconsistent.
Results from 10 case-control trials that focused on physical activity showed general improvements among the intervention group in quality-of-life scores in the short term, but no consistent benefit was seen compared with controls.
Of studies that examined intermediate outcomes, incremental improvements were seen in systolic and diastolic blood pressure levels, as well as in LDL and total cholesterol readings. No association with HDL cholesterol, triglycerides or fasting glucose levels was detected, and only limited evidence regarding intervention effects on incident hypertension, dyslipidemia and diabetes was seen.
Regarding behavioral outcomes, consistent evidence demonstrated that behavioral interventions largely 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.
Response to Public Comment
A draft version of the final recommendation statement was posted for public comment on the USPSTF website from Nov. 29, 2016, to Jan. 2, 2017.
A few commenters suggested that the task force issue separate recommendations on behavioral counseling interventions to promote a healthful diet and on interventions to promote physical activity.
Other respondents contended that the evidence base was different for the two types of behavioral counseling interventions and suggested the USPSTF assign separate and different grades to them.
In response, the task force said it carefully reviewed the evidence on interventions that promoted a healthful diet only, those that promoted physical activity only, and those that promoted both.
"The USPSTF recognizes that the evidence base for these interventions varies, and although the evidence for behavior change was greater for interventions focusing on physical activity, there were no meaningful differences in intermediate or overall health outcomes," said the final recommendation.
"Patients and health care professionals can decide together, based on patient interest and the availability of local resources, whether a focus on a healthful diet, physical activity or both is most appropriate," the recommendation noted.
Some commenters applauded the USPSTF for including language on the benefits of healthful lifestyle behaviors and encouraged more comprehensive definition of the nature of behavioral counseling interventions.
The task force responded by continuing to emphasize that patients gain health benefits from eating a healthful diet and being physically active, and added language defining both.
Finally, the USPSTF clarified that recommended behavioral counseling interventions are more intensive than just general promotion of a healthful diet and physical activity.
Related AAFP News Coverage
USPSTF: Screen Children, Adolescents for Obesity
Task Force Recommends Behavioral Interventions as Needed