Healthful Diet and Physical Activity for CVD Disease Prevention: Counseling -- Adults with CVD Risk Factors


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.

Frequency of Service

Most studies evaluated interventions that combined counseling on a healthful diet and physical activity and were intensive, with multiple contacts (which may have included individual or group counseling sessions) over extended periods. Interventions involved an average of 5 to 16 contacts over 9 to 12 months depending on their intensity. Most of the sessions were in-person, and many included additional telephone contacts.

Risk Factor Information

This recommendation applies to adults aged 18 years or older in primary care settings who are overweight or obese and have known CVD risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome). In the studies reviewed by the USPSTF, the vast majority of participants had a BMI greater than 25 kg/m2.


Clinical

Patient Population Under Consideration

This recommendation applies to adults aged 18 years or older in primary care settings who are overweight or obese and have known CVD risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome). In the studies reviewed by the USPSTF, the vast majority of participants had a BMI greater than 25 kg/m2.

Behavioral Counseling Interventions

Most studies evaluated interventions that combined counseling on a healthful diet and physical activity and were intensive, with multiple contacts (which may have included individual or group counseling sessions) over extended periods. Interventions involved an average of 5 to 16 contacts over 9 to 12 months depending on their intensity. Most of the sessions were in-person, and many included additional telephone contacts. Interventions generally focused on behavior change, and all included didactic education plus additional support. Most included audit and feedback, problem-solving skills, and individualized care plans. Some trials also focused on medication adherence. Interventions were delivered by specially trained professionals, including dietitians or nutritionists, physiotherapists or exercise professionals, health educators, and psychologists.

Many types of intensive counseling interventions were effective. However, it was not clear how the magnitude of the effect was related to the format of the intervention (for example, face-to-face, individual, group, or telephone), the person providing the counseling, the duration of the intervention, or the number of sessions because different combinations of components were effective (see the Implementation sectionfor more information on effective interventions). Because of the intensity and expertise required, most interventions were referred from primary care and delivered outside that setting.

Other Approaches to Prevention

Tobacco use continues to be one of the most important risk factors for CVD. Helping patients with tobacco cessation is a critical component of CVD prevention. The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions to those who use such products. The U.S. Public Health Service has published guidelines to further help clinicians.

Multifaceted approaches with linkages between primary care practices and community resources could increase the effectiveness of interventions. Effective interactions between health care and community interventions, specifically public health and health policy interventions (such as healthy community design and built environment), can support and enhance the effectiveness of clinical interventions (more information is available at www.cdc.gov/healthyplaces). 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 diet and physical activity for persons who are 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. These recommendations are available at www.thecommunityguide.org.

The Million Hearts initiative (http://millionhearts.hhs.gov) aims to decrease the number of heart attacks and strokes by 1 million by 2017. It emphasizes the use of effective clinical preventive services combined with multifaceted community prevention strategies.

In 2010, the U.S. Department of Agriculture and the U.S. Department of Health and Human Services jointly issued the “Dietary Guidelines for Americans”. The latter also issued complementary physical activity guidelines.

Useful Resources

The USPSTF has a wide range of recommendations focusing on CVD prevention. The current recommendation focuses on behavioral counseling that encourages healthy eating and physical activity behaviors to improve cardiovascular health. It does not address weight-loss programs. The USPSTF recommends that clinicians selectively initiate behavioral counseling to promote a healthful diet and physical activity in patients who are not obese and not at increased cardiovascular risk. The USPSTF does not address behavioral counseling in patients with a BMI less than 25 kg/m2 who are at increased risk for CVD. However, for patients with a BMI of 30 kg/m2 or greater, the USPSTF recommends screening these patients for obesity and offering or referring them to intensive, multicomponent behavioral counseling for weight loss.

In another recommendation, the USPSTF recommends screening for lipid disorders in adults according to age and risk factors. It also recommends screening for blood pressure in adults, screening for diabetes in patients with elevated blood pressure, and aspirin use when appropriate. These recommendations are available at www.uspreventiveservicestaskforce.org.
 

Other Considerations

Implementation

The USPSTF defines behavioral counseling interventions as preventive services that are designed to help persons engage in healthy behaviors and limit unhealthy ones. The USPSTF previously described the challenges of developing behavioral counseling recommendations that are feasible for primary care delivery or available for referral from primary care and delivered in other settings. Two well-researched interventions, the DPP (Diabetes Prevention Program) and PREMIER, could feasibly be adapted and delivered in the primary care setting or by local community providers. These interventions are described in further detail because they can be provided by an appropriately trained counselor (typically a dietitian, nutritionist, health educator, or psychologist) and their materials are publicly available. Descriptions of all of the reviewed interventions are included in the evidence review.

The DPP focused on whether weight reduction through a healthful diet and physical activity could prevent or delay the onset of type 2 diabetes. Participants in the lifestyle intervention group received intensive training in diet, physical activity, and behavior modification from a case manager or lifestyle coach. Lifestyle coaches were dietitians or persons with a master's degree and training in exercise physiology, behavioral psychology, or health education. Participants received basic information about nutrition, physical activity, and behavioral self-management. The program addressed problem solving and strategies to deal with eating at restaurants, stress, and lapses. Participants and coaches engaged in face-to-face sessions at least once every 2 months and talked by telephone at least once between visits. The DPP study documents, including coach and participant materials, are available online in English and Spanish (https://dppos.bsc.gwu.edu/web/dppos/lifestyle). At least 1 trial included in the review used an adapted DPP lifestyle intervention in patients recruited from a primary care setting. The trial was conducted in a large multispecialty group practice. Investigators tested a coach-led intervention and a home-based, DVD-facilitated intervention, as well as a Web-based portal for goal setting and self-monitoring. The materials used for the intervention are available online from the University of Pittsburgh Diabetes Prevention Support Center (www.diabetesprevention.pitt.edu).

PREMIER tested whether counseling on comprehensive lifestyle changes could prevent or control high blood pressure. Participants in the intensive intervention group were counseled over 6 months to track their diet (including calorie and sodium consumption) and physical activity and received printed materials about blood pressure and lifestyle changes. In addition, they were taught to follow the Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in fruits, vegetables, and low-fat dairy products and emphasizes reduced intake of saturated and total fat. The intervention was delivered by dietitians or health educators with a master's degree. The materials from this intervention, including participant manuals, food and fitness guides, and food diaries, are available online at www.kpchr.org/research/public/premier/premier.htm. Information about the DASH diet is available from the National Heart, Lung, and Blood Institute.

Research Needs and Gaps

Trials examining the effectiveness of less intensive counseling that can be delivered in the primary care setting, including the minimum intensity, number of interactions, and duration necessary for effectiveness, are needed, as are trials studying the duration of effect beyond 2 to 3 years of follow-up or beyond the intensive counseling intervention period. The effectiveness of interventions for physical activity alone has not been well-studied. Trials examining the interaction or potentiation of clinical counseling and community-based lifestyle interventions are needed. Finally, the lack of direct evidence of effect on CVD events is an important research gap. Advances in management of CVD risk factors and relatively low rates of CVD events in study populations present a challenge to researchers trying to assess differences in CVD outcomes.

Rationale

No information available.


Others

The American Heart Association recommends 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 American College of Sports Medicine has published recommendations for health professionals who counsel healthy adults on individualized exercise programs. It recommends 150 minutes of moderate-intensity exercise per week and 2 to 3 days of resistance, flexibility, and neuromotor exercises per week. Previous statements by the American Academy of Family Physicians about counseling for diet and physical activity have been consistent with those of the USPSTF; it is currently updating its recommendations.


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