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Preventing Cardiovascular Disease in At-risk Adults

USPSTF Recommends Clinicians Offer Behavioral Counseling

December 3, 2020, 12:32 pm News Staff -- On Nov. 24, the U.S. Preventive Services Task Force issued a final recommendation statement, final evidence review and evidence summary on behavioral counseling interventions to promote a healthy lifestyle and prevent cardiovascular disease in adults with cardiovascular risk factors.

Based on the available evidence, the task force recommended that clinicians offer or refer adults who are at risk for CVD to interventions that promote a healthy diet and physical activity to help them stay healthy. This is a “B” recommendation, and applies to adults with specific cardiovascular risk factors such as hypertension, elevated lipid levels or dyslipidemia, as well as to those who have a combination of risk factors such as metabolic syndrome.

The task force stated that the recommendation does not apply to adults with other known modifiable cardiovascular risk factors, such as abnormal blood glucose levels, obesity or smoking, as these populations are included in other recommendations.

“Behavioral counseling interventions aimed at improving diet and increasing physical activity can help prevent cardiovascular disease,” said task force member Marti Kubik, Ph.D., R.N., in a press release. “Because almost half of all adults in the U.S. have at least one risk factor for cardiovascular disease, it is good news that there are effective interventions available that clinicians can offer or refer patients to reduce that risk.”

According to the CDC, heart disease and stroke are the first- and fifth-leading causes, respectively, of death in the United States. Altogether, the agency estimates that about one-third of all deaths in the United States each year – more than 868,000 – are caused by CVD events.

Update of Previous Recommendation

The final recommendation statement updates the task force’s 2014 recommendation statement on the topic. The 2014 statement recommended that clinicians offer or provide referrals for intensive behavioral counseling interventions to adult patients who were overweight or obese and who had known risk factors for CVD, including hypertension, dyslipidemia, impaired fasting glucose or glucose intolerance and metabolic syndrome. The AAFP supported the 2014 recommendation.

Story Highlights

While the new final recommendation statement is consistent with the 2014 recommendation, which also received a “B” grade, the task force emphasized that it no longer includes adults who have impaired glucose tolerance or type 2 diabetes. Interventions for these populations are covered under a separate recommendation.

The task force noted that it has also issued recommendation statements on behavioral counseling interventions to promote a healthy diet and physical activity for CVD prevention in adults without known risk factors, behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults, and behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women.

Relevant Findings

To update its 2014 recommendation, the USPSTF commissioned a systematic evidence review of 94 trials. Although some trials evaluated diet-only interventions or interventions that focused only on physical activity, most trials evaluated interventions that combined both.

In trials that reported intermediate health outcomes, the task force found that interventions that involved counseling on diet and physical activity led to statistically significant improvements in a number of measurements, including systolic blood pressure, diastolic blood pressure, total cholesterol level, low-density lipoprotein cholesterol level, fasting glucose level, body weight and body mass index. For all outcomes, improvements were observed at 12 to 24 months of followup.

In trials that reported outcomes related to health behaviors, the task force found that overall, behavioral counseling resulted in small but statistically significant improvements in saturated fat consumption, increased consumption of fruits and vegetables and increased fiber intake.

Regarding physical activity, there was no consistent evidence of benefit reported among a review of 50 trials. However, in trials that had a study-defined physical activity goal, intervention groups had a higher likelihood of meeting that goal.

“Interventions to promote a healthy diet and physical activity vary, but typically involve a professional who provides education, helps people set goals, shares strategies and stays in regular contact to provide support,” observed family physician and task force member John Epling, M.D., M.S.Ed. “People at high risk should talk to their primary care clinician about interventions that can help.”

Recommended Tools and Resources

The task force also recommended several resources for clinicians and patients under the “Additional Tools and Resources” section of the final recommendation statement. They are

Response to Public Comment

A draft version of the recommendation statement was posted for public comment on the USPSTF website from May 12 to June 8, 2020.

The task force received several comments from individuals who noted that the interventions in some studies were provided by nonmedical professionals and requested clarification on who could provide them. In response, the USPSTF added language clarifying that both medical and nonmedical professionals could provide these interventions.

Several respondents suggested that the recommendation highlight interventions such as low-carbohydrate and plant-based diets, intermittent fasting, telehealth and wearable technologies. The task force responded by stating that only two diets (Dietary Approaches to Stop Hypertension and Mediterranean) were evaluated in more than one study and that recommendations from plant-based and low-carbohydrate diets are included in most recommendations for a healthy diet. The task force also called for more research on telehealth and wearable technologies.

Finally, several commenters requested additional information on how to provide behavioral counseling services to diverse populations. The USPSTF responded by stating that it recognizes that large disparities exist in access to resources that support increased physical activity and a healthy diet and provided links to the previously cited resources to help clinicians address this issue.

Up Next

The AAFP’s Commission on Health of the Public and Science plans to review the USPSTF’s final recommendation statement and evidence summary and will then determine the Academy’s stance.