USPSTF Issues Recommendations on Lifestyle Change Counseling to Prevent CVD

The US Preventive Services Task Force (USPSTF) on Tuesday issued its final recommendation on referral by primary care professionals (PCPs) of patients without cardiovascular disease (CVD) risk factors for behavioral counseling aimed at promoting healthy eating habits and guideline-recommended physical activity.

The recommendation, consistent with the USPSTF guidance released in 2017, advises that such a referral be an individualized one, with PCPs and their patients who do not have CVD risk factors deciding together whether counseling support on maintaining a healthy diet and physical activity routine might help prevent a CV event such as myocardial infarction or stroke. The task force assigned the recommendation a grade “C” for strength.

In the recommendation the task force emphasizes that CVD remains the leading cause of death in the US, citing the stark prediction that by 2035, nearly half of US 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,” they write. “All persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and physical activity.”

The USPSTF recommendation is based on a systematic review of evidence commissioned by the task force to update the 2017 guidance. The resulting literature review, published in JAMA, included 113 randomized clinical trials (n=129 993), the majority of which were conducted in the US and included both men and women. Mean age of participants ranged from 18.5 to 79.5 years and average BMI was in the overweight range (27.8 kg/m²).

Sixty-nine trials reported participant race and ethnicity. Of these, most participants were White persons; in 17 trials, Asian persons, Black persons, Hispanic/Latino persons, or Native American/American Indian persons comprised more than two-thirds of participants.

Review authors concluded that behavioral interventions focused on healthy diet and physical activity provided to persons without known CVD risks were associated with small but statistically significant benefits for across categories of important intermediate health outcomes, ie, blood pressure, LDL-C, and adiposity. Effects of interventions on dietary and physical activity behaviors were small to moderate. Harmful effects, researchers say, were rare.

The final recommendation, according to the USPSTF, applies to adults ≥18 years old without known CVD risk factors, including hypertension, elevated blood pressure, dyslipidemia, impaired fasting glucose or impaired glucose tolerance, metabolic syndrome, or an estimated 10-year CVD risk of ≥7.5%.

READINESS, RESOURCES

In addition to a shared decision-making approach to a discussion of counseling or referral for counseling on behavioral interventions, the task force stresses the importance of gauging an individual patient’s readiness to engage in the types of changes that may be recommended, given the low chance of benefit if they are not. Even more important is an exploration of the availability of and access to the resources needed to support improved dietary composition and increased physical activity as well as other sources of inequities in social determinants of health.

“When determining which patients might benefit from counseling interventions, healthcare professionals should consider the patient’s goals and motivations, activity, and ability,” says Task Force member Michael Cabana, MD, MA, MPH.

“With many people facing barriers to eating healthy and physical activity," she continues, "we encourage healthcare professionals to ask those patients who may benefit from counseling about their individual circumstances, including availability of healthy food and exercise opportunities.”

“With many people facing barriers to eating healthy and physical activity, we encourage healthcare professionals to ask those patients who may benefit from counseling about their individual circumstances, including availability of healthy food and exercise opportunities.”

Writing in an accompanying editorial in JAMA, Carl Lavie, MD, Barry Franklin, PhD, and Keith Ferdinand, MD, emphasize that the USPSTF data, along with other recent reports "suggest that the single greatest opportunity to improve health and reduce premature death lies in favorably modifying unhealthy lifestyle behaviors."

Barriers to broad-based sucesss in such change, they add, however, are "inexorably embedded within the social determinants of health."

They continue, "The likelihood that patients will or will not engage in a particular lifestyle behavior is governed by myriad socioeconomic, attitudinal, and cultural factors. Lack of or a suboptimal social support system, social isolation, or financial difficulties are often cited as common barriers to achieving lasting lifestyle behavior changes."

"Unfortunately, despite prior USPSTF recommendations, as a society, the US remains stubbornly deficient in decreasing and eventually eliminating racial/ethnic disparities in CVD outcomes and implementing the appropriate multilevel approaches. " They conclude: "The future health of the US population is dependent on these efforts."

Reference: Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults without known cardiovascular disease risk factors: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2022;328(4):375-388. doi:10.1001/jama.2022.7408

USPSTF Final Recommendation Statement