Healthful Diet and Physical Activity: Behavioral Counseling -- Adults without obesity who do not have known cardiovascular disease risk factors


General

Grade: C

Specific Recommendations

The USPSTF recommends that primary care professionals individualize the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to promote a healthful diet and physical activity. Existing evidence indicates a positive but small benefit of behavioral counseling for the prevention of cardiovascular disease (CVD) in this population. Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling.   See the "Useful Resources" section for more information on how this recommendation fits into the USPSTF’s suite of recommendations on CVD prevention.

Frequency of Service

See Clinical Considerations

Risk Factor Information

common risk factors for CVD (hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes)


Clinical

Patient Population Under Consideration

This recommendation applies to adults 18 years or older who are of normal weight or overweight, with a BMI between 18.5 and 30 (calculated as weight in kilograms divided by the square of height in meters). It does not apply to persons who have known CVD risk factors (hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes) or persons with obesity or who are underweight.

Behavioral Counseling Interventions

The USPSTF reviewed 88 trials with more than 120 distinct interventions focused on promoting a healthful diet, physical activity, or both. Dietary messages documented in the interventions typically focused on general heart-healthy eating patterns (increased consumption of fruits, vegetables, fiber, and whole grains; decreased consumption of salt, fat, and red and processed meats).34 This guidance is generally consistent with major dietary recommendations, including the US Department of Health and Human Services' 2015–2020 Dietary Guidelines for Americans.5 Similarly, national guidelines suggest that US adults should perform at least 150 minutes of moderate-intensity or at least 75 minutes of vigorous-intensity physical activity per week, or an equivalent combination of moderate- and vigorous-intensity physical activity, and also should perform strengthening activities at least twice per week.6 Physical activity messages used in the reviewed interventions emphasized gradually increasing aerobic activities to recommended levels, with many studies emphasizing walking.3

Interventions categorized as low intensity included print- or web-based materials with tailored feedback and tools for behavior change, ranging from 1-time mailings to monthly mailings over 3 years. Medium- and high-intensity interventions commonly included face-to-face individual or group counseling or both, with telephone, email, and text message follow-up. These more intensive interventions ranged in duration from 4 weeks to 6 years, with the active intervention period often lasting for 6 months. Interventions were delivered by primary care clinicians, health educators, behavioral health specialists, nutritionists or dieticians, exercise specialists, and lay coaches. Behavioral change techniques included goal setting and planning, monitoring and feedback, motivational interviewing, addressing barriers to change, increasing social support, and general education and advice. Adherence to all interventions was relatively high; adherence to high-intensity interventions was generally lower than for less-intensive interventions. Overall, there appeared to be a dose-response effect, with higher-intensity interventions demonstrating greater and statistically significant benefits. However, this dose-response effect was not seen for interventions targeting physical activity only, among which some low-intensity interventions demonstrated benefit.3

Additional Approaches to Prevention

The USPSTF recognizes the important contributions of public health approaches to improving diet, increasing physical activity levels, and preventing CVD. The Community Preventive Services Task Force recommends several community-based interventions to promote physical activity, including community-wide campaigns, social support interventions, school-based physical education, and environmental and policy approaches. It also  recommends programs promoting healthful diet and physical activity for persons at increased risk for type 2 diabetes on the basis of strong evidence of the effectiveness of these programs in reducing the incidence of new-onset diabetes.7

Useful Resources

The USPSTF has evaluated the evidence on several aspects of CVD prevention in adults with and without common risk factors, including behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention in adults with cardiovascular risk factors,8 screening for and management of obesity in adults,9 and screening for abnormal blood glucose levels and type 2 diabetes mellitus.10

In other recommendation statements, the USPSTF had recommended screening for high blood pressure,11 use of statin medications in persons at risk for CVD,12 screening and counseling for tobacco smoking cessation,13 and aspirin use in certain persons for CVD primary prevention.14

In addition, the US Department of Health and Human Services has published national dietary and physical activity guidelines for Americans.56


Rationale

Importance

Cardiovascular disease, which includes myocardial infarction and stroke, is the leading cause of death in the United States.1 Adults who adhere to national guidelines for a healthful diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not. All persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and appropriate physical activity.2

Benefits of Behavioral Counseling Interventions

The USPSTF found adequate evidence that behavioral counseling interventions provide at least a small benefit for reduction of CVD risk in adults without obesity who do not have the common risk factors for CVD (hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes). Behavioral counseling interventions have been found to improve healthful behaviors, including beneficial effects on fruit and vegetable consumption, total daily caloric intake, salt intake, and physical activity levels. Behavioral counseling interventions led to improvements in systolic and diastolic blood pressure levels, low-density lipoprotein cholesterol (LDL-C) levels, body mass index (BMI), and waist circumference that persisted over 6 to 12 months. The USPSTF found inadequate direct evidence that behavioral counseling interventions lead to a reduction in mortality or CVD rates.

Harms of Behavioral Counseling Interventions

The USPSTF found adequate evidence that the harms of behavioral counseling interventions are small to none. Among 14 trials of behavioral interventions that reported on adverse events, none reported any serious adverse events.

USPSTF Assessment

The USPSTF concludes with moderate certainty that behavioral counseling interventions to promote a healthful diet and physical activity have a small net benefit in adults without obesity who do not have specific common risk factors for CVD (hypertension, dyslipidemia, abnormal blood glucose levels, and diabetes).

Although the correlation among healthful diet, physical activity, and CVD incidence is strong, existing evidence indicates that the health benefit of behavioral counseling to promote a healthful diet and physical activity among adults without obesity who do not have these specific CVD risk factors is small.


Others

Other Considerations  Although the evidence review that supports this recommendation did not exclude studies that enrolled persons who were overweight or had obesity, the USPSTF had previously commissioned a separate evidence review focused on screening for and management of obesity in adults.15 Based on that review, the USPSTF recommended offering or referring adults with obesity to intensive, multicomponent behavioral interventions (B recommendation).9 To highlight this benefit, the USPSTF decided to exclude persons with obesity from the current recommendation. In a separate recommendation statement, the USPSTF recommended offering or referring adults to intensive behavioral counseling interventions to promote a healthful diet and physical activity if they are overweight and have hypertension, dyslipidemia, or other CVD risk factors.8 The USPSTF recognizes that persons with hypertension or dyslipidemia who are not overweight or do not have obesity are likely to receive at least as great a benefit from behavioral counseling as adults without these risk factors. The USPSTF therefore suggests that health care professionals also consider offering or referring adults who are not overweight or do not have obesity but who have hypertension, dyslipidemia, or both to behavioral counseling on an individual basis. Research Needs and Gaps The USPSTF found very limited evidence on the effect of behavioral interventions to reduce sedentary behaviors. Given the link between sedentary behaviors and cardiovascular risk, this is an important area for future research. Continued research on individually tailored, computer-based interventions that can be delivered via the internet, social media, and text messaging is needed. Novel research methods should be applied to understand longer-term health effects of behavioral interventions and to improve understanding of the association between changes in behaviors, changes in intermediate risk factors, and improvements in health outcomes.   Recommendations of Others In 2010, the American Heart Association23 recommended that clinicians use counseling interventions to promote a healthful diet and physical activity that include a combination of 2 or more of the following strategies: setting specific, proximal goals; providing feedback on progress; providing strategies for self-monitoring; establishing a plan for frequency and duration of follow-up; using motivational interviews; and building self-efficacy. The recommendations suggest that intervention support should be offered to all patients. Previous statements by the American Academy of Family Physicians24 about behavioral counseling to promote a healthful diet and physical activity have been consistent with those of the USPSTF. The American College of Physicians does not currently have a clinical recommendation on behavioral counseling to promote a healthful diet or physical activity in adults.   Updates of  Previous USPSTF  Recommendations This is an update of the 2012 USPSTF recommendation.22 In 2012, the USPSTF recommended that primary care professionals selectively provide or refer patients who do not have hypertension, dyslipidemia, diabetes, or CVD to behavioral counseling to promote a healthful diet and physical activity rather than incorporating counseling into the routine care of all adults. The current recommendation is based on a new systematic evidence review that included 50 trials from the previous review and an additional 38 new trials. The current recommendation is similar to the previous recommendation. Given the recent publication of recommendations focused on behavioral counseling in adults at higher risk for CVD,8 adults with obesity,9 and adults with abnormal blood glucose levels or diabetes,10 the current recommendation focuses on persons without these risk factors.


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