Individualize behavioral counseling in those without CVD risk factors, USPSTF says

In an update consistent with its 2017 recommendation, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians individualize the use of behavioral counseling interventions to promote a healthy diet and physical activity in adults without risk factors for cardiovascular disease (CVD).

The U.S. Preventive Services Task Force (USPSTF) recently updated and reaffirmed its previous grade-C recommendation that clinicians treating adults without risk factors for cardiovascular disease (CVD) individualize the decision to offer or refer to behavioral counseling interventions to promote a healthy diet and physical activity.

To update its 2017 recommendation, the USPSTF commissioned a review of the evidence on the benefits and harms of behavioral counseling interventions in adults without known CVD risk factors, including hypertension, dyslipidemia, impaired fasting glucose or glucose tolerance, and mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater. The recommendation statement and evidence report were published July 26 by JAMA.

The review included 113 randomized clinical trials (129,993 patients), 60 of which were conducted in the U.S. and 33 of which were published since the 2017 statement. All trials reported at least six months of follow-up, and 63 trials reported 12 months or longer. In an analysis of 109 trials that reported the effect of behavioral counseling on diet, physical activity, or sedentary health behaviors, the USPSTF found sufficient evidence that 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. In an analysis of 43 trials that reported effects on intermediate outcomes such as blood pressure or adiposity measures, the USPSTF found sufficient evidence that behavioral counseling interventions for a healthy diet, physical activity, or both were associated with lower blood pressure, low-density lipoprotein cholesterol, and adiposity measures (body mass index, weight, and waist circumference) after six to 12 months. There was little direct evidence on all-cause mortality, CVD-related mortality, CVD events, or quality of life. In addition, only 23 trials specifically reported on harms or lack of harms of behavioral counseling interventions; overall, harms were rare, and there were no significant differences between intervention and control groups in adverse events, serious adverse events, musculoskeletal injuries, or falls.

As physical activity has declined and obesity and cardiometabolic diseases have increased, efforts to reverse these trends are “desperately needed,” an accompanying editorial noted. “Although the modulations described by the USPSTF in CVD risk factors were only modest, the improvements in physical activity were more substantial,” the editorialists wrote. Among other limitations, the review had limited data on the underlying CVD risk of the populations studied and was unable to directly assess the relationship between dietary patterns, physical activity levels, and health outcomes, the editorial said.

The recommendation applies to the relatively small proportion of U.S. adults without obesity, hypertension, dyslipidemia, prediabetes, or diabetes, another editorial noted. “For everyone else—the great majority of US adults—clinicians should provide or refer them to intensive behavioral counseling,” the editorialist wrote.

A third editorial added that the updated USPSTF recommendations are narrower than those of other organizations, including the American College of Sports Medicine, the American Heart Association, HHS, and Veterans Affairs. “That is, these other organizations recommend that health care professionals provide behavioral counseling on eating and physical activity to all of their adult patients, regardless of chronic conditions or risk factors,” the editorialist wrote.