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Am Fam Physician. 2022;106(4):online

Related Putting Prevention Into Practice: Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for CVD Prevention in Adults Without CVD Risk Factors

As published by the USPSTF.

What does the USPSTF recommend?For adults 18 years or older without known CVD risk factors:
Individualize the decision to offer or refer adults without CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
Grade: C
To whom does the recommendation apply?This recommendation applies to adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose or glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater. Interventions to reduce CVD risk in adults with known modifiable risk factors (i.e., hypertension or dyslipidemia) and weight management interventions are addressed in separate USPSTF recommendations.
What's new?This recommendation is consistent with the 2017 USPSTF recommendation.
How to implement this recommendation?The USPSTF recommends selectively offering or providing behavioral counseling interventions to patients based on clinician professional judgment and patient preferences.
  • Common dietary counseling advice promotes increased consumption of fruits, vegetables, and fiber; reduced consumption of saturated fats, sodium, and sugar-sweetened beverages; or both.

  • Physical activity counseling often encourages patients to gradually increase aerobic activity (walking is often emphasized) to achieve at least 150 minutes (2 hours and 30 minutes) per week of equivalent moderate-intensity activity.

  • Interventions can be delivered individually, in a group, or both, with or without follow-up (telephone calls or emails), or delivered remotely through a combination of print materials, telephone calls, technology-based activities, or some combination thereof.

  • Typical counseling techniques include behavioral change techniques such as goal setting, problem solving, and self-monitoring; approaches including motivational interviewing principles or portions of the “5 A's” Model (assess, advise, agree, assist, and arrange) are common.

  • A wide range of specially trained professionals can deliver these interventions.

  • Interaction time with a clinician may range from 30 minutes to 6 hours over 6 months or longer.

What additional information should clinicians know about this recommendation?In determining whether behavioral counseling interventions are appropriate, patients and clinicians should consider the following.
  • Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling.

  • Higher-intensity counseling interventions may vary in availability and feasibility in clinical settings.

  • Adoption of healthy behavior advice may be increased by tailoring behavioral counseling to consider patient motivations and goals, activity level and ability, circumstances, preferences, and overall health status, as well as availability of healthy eating establishments, grocery stores, parks, sidewalks, bicycle trails, safe/pleasant walking paths close to home or workplace, traffic, public transportation, crime, and pollution levels.

Why are this recommendation and topic important?
  • CVD, which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the United States.

  • By 2035, nearly half of U.S. adults are anticipated to have some form of CVD.

  • A large proportion of CVD cases can be prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet.

  • 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.

  • Important disparities in diet and physical activity behaviors exist across the U.S. population. Social determinants of health and systemic racism contribute to differences in healthy diet and physical activity by influencing healthy food availability and physical activity barriers and opportunities.

What are other relevant USPSTF recommendations?
  • Behavioral counseling interventions to promote a healthy diet and physical activity for CVD prevention in adults with cardiovascular risk factors.

  • Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults.

  • Information on additional recommendations related to cardiovascular health is available at

What are additional tools and resources?
Where to read the full recommendation statement?Visit the USPSTF website or the JAMA Network website ( to read the full recommendation statement. This includes more details on the rationale of the recommendation, including benefits and harms; supporting evidence; and recommendations of others.

The USPSTF recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of USPSTF recommendation statements published in AFP is available at

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