USPSTF Recommends Behavior Counseling to Improve Diet and Exercise Habits

The United States Preventive Services Task Force (USPSTF) is once again recommending clinicians refer select adults without cardiovascular disease risk factors to behavior counseling to encourage healthy changes to diet and exercise habits.

Behavior counseling, which could be one-on-one, group-based, or even delivered remotely through a combination of print materials, telephone calls, or other technology-based activities, should include dietary advice to promote increased consumption of fruits, vegetables, and fiber and decreased intake of saturated fats, sodium, and sugar-sweetened drinks, according to the guidance. It should also aim to get adults doing at least 150 minutes per week of moderate-intensity aerobic activity. 

The decision to refer adults to counseling needs to be individualized, according to the USPSTF, but the evidence suggests that such interventions have a “small net benefit” on altering these important lifestyle behaviors (grade C). While there is not enough data to say such counseling can reduce CVD events or mortality, there is “adequate evidence” to say it provides a small benefit on blood pressure, lipids, and body weight.   

The latest recommendation, which was published in the July 26, 2022, issue of JAMA, is consistent with the 2017 USPSTF recommendation to refer certain low-risk adults to behavior counseling.

Salim Virani, MD, PhD (Michael E. DeBakey VA Medical Center, Houston, TX), immediate past chair of the American College of Cardiology’s (ACC) section on prevention of cardiovascular disease, emphasized that the USPSTF recommendations apply to only a small segment of the population: those without CVD or risk factors who are at a low 10-year risk of CVD events.

These people are healthy for their age but they don’t remain risk-free—it’s only a matter of time. Salim Virani

“These are mostly going to be young individuals,” he told TCTMD. “I think it’s important to recognize that these aren’t people coming to clinicians for primary prevention. They’re out in the community, and what we need to focus on is primordial prevention where they don’t develop the risk factors in the first place. I don’t think clinicians should take this lightly.”

Based on large epidemiological studies, poor diet and lack of physical activity are associated with a range of poor health outcomes, including CVD, cancer, and mental health, among others, and most people are aware of that connection. However, the best way to intervene and modify unhealthy behaviors remains the ultimate challenge, said Virani.

“These interventions, I think, will need to be done outside the office, or in tandem with the physician’s office,” said Virani. “That’s where the research need is right now, I would say. These people are healthy for their age but they don’t remain risk-free—it’s only a matter of time—so what’s the best way to reach these people and what’s the best way to motivate them?”

Getting young adults to shift their thinking beyond the next few years to their entire lifetime is critical, he said.

Behavior Counseling Not Widely Offered

The USPSTF recommendation is based on an updated evidence report and systematic review of randomized clinical trials of behavioral counseling interventions targeting dietary changes, increased physical activity, and decreased sedentary time. The review, which was led by Carrie Patnode, PhD (Kaiser Permanente Northwest, Portland, OR), included 113 clinical trials with 129,993 adults without CVD risk factors. Of these, 15 included health-related outcomes as study endpoints, with three that focused solely on CVD-related outcomes, the largest of which was the Women’s Health Initiative Dietary Modification Trial (WHI-DMT).

With respect to CVD events, the reviewers found mixed results. WHI-DMT showed that a counseling intervention in the 47,179 women in the study had no effect on hard outcomes over 8.5 years of follow-up. Combining two smaller studies—PACE-UP and PACE-Lift—did show that counseling reduced nonfatal CVD events, however. In terms of CVD mortality and morbidity, evidence suggests little to no benefit with behavioral counseling, the reviewers say.  

Although the data were weak for showing a reduction in CVD events, dietary and exercise behavioral counseling was associated with small, albeit statistically significant, improvements in blood pressure, LDL cholesterol, and adiposity-related outcomes, such as body mass index, weight, and waist circumference. On the key question of diet and physical activity, counseling was linked with better dietary outcomes, such as reduced saturated fat consumption and greater intake of fruit, vegetables, and fiber, and increased physical activity levels at 6 months to 1.5 years of follow-up when compared with a control group. 

There was no evidence of harm with behavioral counseling.

Mahmoud Al Rifai, MD, MPH (Houston Methodist DeBakey Heart and Vascular Center, TX), a member of the ACC’s section on prevention of cardiovascular disease, said that cardiologists don’t frequently encounter patients without CVD or risk factors, noting, like Virani, that it represents a smaller segment of the population given the increase in diabetes, metabolic syndrome, and obesity in the US. With all patients, he said, the goal is to reinforce healthy habits, including the American Heart Association’s “Life’s Essential 8,” a recent reworking that includes sleep as a metric of cardiovascular health status.

“I still encourage all my patients, even those without any risk factors, to keep up their healthy habits,” Al Rifai told TCTMD. “Unfortunately, we’re not really taught much about motivational techniques or lifestyle coaching around nutrition, diet, or exercise. It’s easy to say eat healthy or exercise, but it’s not a pill that you can just prescribe. It’s not hard, concrete guidance that the patient can use.”

If the patient without CVD risk factors is up for behavioral counseling, Al Rifai said he would encourage it. The USPSTF recommendation states that the decision should be individualized, he noted, adding that some adults can simply keep doing what they’re doing if they’re on the right track with diet and exercise while others may require additional help to get there.

Although there is no conclusive data showing that behavioral interventions reduce CVD or mortality, Virani pointed out that patients without CVD risk factors represent a very low-risk population. In randomized studies assessing clinical outcomes, even with long-term follow-up, there were very few CVD events.

Unfortunately, we’re not really taught much about motivational techniques or lifestyle coaching around nutrition, diet, or exercise. Mahmoud Al Rifai

“If we start out with people who are very healthy to begin with—healthy in the general sense that they haven’t developed any risk factors—then the effect size of any intervention will be small,” he said. “I hope clinicians don’t interpret this small benefit as no benefit.” Even the modest effects of counseling interventions on CVD risk factors are important when considered from a population level, he added.

“In terms of the long-term impact, the changes are extremely important,” said Virani. “I don’t want physicians to be too selective in terms of offering behavioral counseling. They might think it’s a C recommendation, and maybe it doesn’t even need to be brought up, but I think it should. After that, shared decision-making, of course, but it shouldn’t be ignored.” 

Virani also noted that when adults develop risk factors, some communities are harder hit than others.

“A lot of that burden occurs in communities that are underserved or are vulnerable,” he said. “We need to get to those segments of the population where they haven’t developed these risk factors but who remain at extremely high risk. Not in the traditional sense of risk with a risk calculator, but where we know a lot of them will develop risk factors with time.”

White House Conference Coming Soon

In an editorial, Dariush Mozaffarian, MD, DrPH (Tufts University, Boston, MA), points out that healthy habits are influenced by sociocultural circumstances, “such as levels of educations and income, community environment, and prejudice and structural racism.” As a result, addressing disease conditions and health disparities caused by poor lifestyle will require government, community, and other systems-level approaches.

Mozaffarian estimated that the USPSTF recommendation applies to just 12.2% of people, even less if adults with obesity were excluded. “For everybody else—the great majority of US adults—clinicians should provide, or refer them to intensive behavioral counseling,” according to Mozaffarian. Unfortunately, even in these higher-risk patients, such counseling is not occurring, he says. In the US, only 25% of patients with diabetes, and 15% of other patients, receive any diet or exercise counseling, he notes.

Mozaffarian says that given the scope of health, equity, and economic consequences resulting from poor diet and inadequate exercise, this is an area that is “ripe for meaningful new federal and private sector investment in research.”

He adds that some large healthcare systems are studying food- and exercise-based interventions, and the US government is starting to pay attention, too. Later this year, the White House is hosting a conference on hunger, nutrition, and health. This conference, the first in 50 years, will be focused on improving nutrition and physical activity levels and reducing diet-related diseases and health disparities.