According to a recommendation from the US Preventive Services Task Force, clinicians should individualize the decision to offer or refer adults without cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
Carol M. Mangione, MD, MSPH
Recently, the US Preventive Services Task Force (USPSTF) commissioned a review on behavioral counseling interventions to promote healthy behaviors in adults without cardiovascular disease (CVD) risk factors, updating its 2017 recommendation.1 Investigators noted that most US adults do not consume healthy diets or engage in physical activity at recommended levels even though a large proportion of CVD cases can be prevented by addressing modifiable risk factors.2
The observational evidence from the meta-analysis of the prospective cohort studies demonstrated small changes in intermediate outcomes such as lower blood pressure and were associated with small reductions in risk of cardiovascular-related mortality and all-cause mortality. Corresponding author Carol M. Mangione, MD, MSPH, chief, Division of General Internal Medicine and Health Services Research, and Levy Endowed Chair in Medicine, David Geffen School of Medicine, University of California, Los Angeles, and colleagues, wrote, “the USPSTF found little direct evidence on the effectiveness of behavioral counseling interventions on all-cause mortality, CVD-related mortality, CVD events (such as myocardial infarction or stroke), or quality of life.”1
The USPSTF included 113 randomized clinical trials in its review (n = 129,993)and all trials were reported with at least 6 months of follow-up.1 Most of the intervention groups focused on physical activity (48.1%), healthy diet (19.1%), or both (32.5%), and 52.9% of trials included at least 1 in-person counseling session, whereas 42.7% of trials involved sessions delivered completely remotely.
Findings showed that counseling interventions for a healthy diet, physical activity, or both, were associated with modest increases in physical activity levels and some improvements in dietary health behaviors. Participants of physical activity interventions increased their physical activity by 33 minutes per week (95% CI, 21.9-44.2) and had higher chance of meeting physical activity recommendations after 6 to 12 months (95% CI, 1.18-1.67) compared with the control group. On average, participants of healthy diet interventions increased fruit and vegetable intake (1.11 servings per day; 95% CI, 0.41-1.81) and fiber intake (0.24; 95% CI, 0.05-0.43) and decreased saturated fat intake (−0.53; 95% CI, −0.78 to −0.27) compared with the control group.1
Even after adjusting for multiple confounding variables including recognized factors associated with cardiovascular diseases, PTSD plus insomnia remained an independent factor of major adverse cardiovascular events.
There was also sufficient evidence identified for behavioral counseling interventions for a healthy diet, physical activity, or both, associated with lower blood pressure, low-density lipoprotein cholesterol (LDL-C), and adiposity measures (BMI, weight, and waist circumference) after 6 to 12 months. Diet and physical activity interventions were associated with lower systolic blood pressure (−0.8 mm Hg; 95% CI, −1.30 to −0.31), diastolic blood pressure (−0.42 mm Hg; 95% CI, −080 to −0.04), LDL-C level (−2.20 mg/dL; 95% CI, −3.80 to −0.60), and adiposity-related outcomes such as weight (−1.07 kg; 95% CI, −1.62 to −0.52), BMI (−0.32; 95% CI, −0.51 to −0.13), and waist circumference (−0.81 cm; 95% CI, −1.32 to −0.30]). Overall, the high-intensity interventions (>360 minutes) were associated with greater changes in intermediate outcomes such as lower LDL-C and adiposity measures.
Mangione noted that when determining whether behavioral counseling interventions are appropriate, patients and clinicians should consider persons who are interested and ready to make behavioral changes as they may be more likely to benefit from the intervention. In addition, they should take into consideration, “higher-intensity counseling interventions that may vary in availability and feasibility in clinical settings.”
The USPSTF concluded that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors. The task force suggested that future research should ensure that patient-reported quality of life outcomes related to cardiovascular health are consistently measured and reported. Additionally, future research that is adequately powered and of sufficient follow-up duration is needed in patients without known CVD risk.
