Identification and control of cardiovascular disease (CVD) risk factors are critical components in the prevention of CVD.1 Advantages of control of risk factors have been documented in numerous studies and have contributed substantially to national and global health policies for prevention of chronic disease. For example, Stamler et al2 studied 5 cohorts of young adult and middle-aged men, as well as middle-aged women, from the Chicago Heart Association Detection Project in Industry and screenees from the Multiple Risk Factor Intervention Trial. “Healthy factors” were defined as normal levels of major CVD risk factors (serum total cholesterol level less than or equal to 200 mg/dL; blood pressure less than or equal to 120/80 mm Hg; no diabetes; and no current smoking). Over 16 to 22 years of follow-up, Stamler et al observed 70% to 85% lower cardiovascular mortality, 40% to 60% lower total mortality, and 6 to 9 years’ greater predicted life expectancy among individuals having all of these healthy factors compared with those who had 1 or more elevated risk factors. Similar results were found among younger women (<40 years) from the Chicago cohorts and in longer-term follow-up.3
The repeated observation that excellent control of CVD risk factors is associated with lower risks for CVD, cancer, diabetes, chronic lung diseases, and kidney diseases influenced the development in 2010 of the concept of “ideal cardiovascular health” by the American Heart Association,4 now in wide use throughout the world. Ideal cardiovascular health is used both as a risk factor goal and also as a means of evaluating risk changes over time.
Control of CVD risk factors traditionally has involved 2 complementary approaches—a general plan for everyone (public health approach) and a targeted intervention for people with specific risk factors (the clinical or high-risk approach). The public health approach is based on the well-known principle that a small shift in risk to better control for the entire population can achieve as much, or greater, effect in disease prevention than targeted interventions focusing only on specific subsets of the population. This concept was popularized in 1985 by Rose and has become known as the “Rose Prevention Paradox.”5 Both approaches are widely accepted, and both are needed for maximal control of CVD. The need to consider prevention efforts for entire populations, while also treating specific patients in clinical settings, provides important context for interpreting the US Preventive Services Task Force recommendation statement guideline6 and the accompanying evidence summary7 in this issue of JAMA.
The task force guideline recommendation statement6 addresses a very specific aspect of the clinical approach to prevention. The guideline is focused only on adults without obesity who do not have known CVD risk factors. Focusing on this segment of adults, the guideline recommends that clinicians treating such patients should individualize the decision to offer or refer adults to behavioral counseling to promote a healthful diet and physical activity. The evidence grade for this limited recommendation is C. The hesitation of the guideline to recommend, with greater enthusiasm, counseling in the clinical setting for selected adult patients is based exclusively on the quality of the evidence on dietary counseling 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) in this specific limited population.
In addition, the task force considered physical activity interventions that emphasized gradually increasing aerobic activities to recommended levels, with many studies emphasizing walking. But, importantly, the guideline does not stop there and should not be regarded as anything less than full endorsement of the importance of control of CVD risk factors. Indeed, the guideline also states that 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. In keeping with the importance of controlling CVD risk factors in all adults, the guideline states that “All persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and appropriate physical activity.”6
Several lessons from this guideline and associated literature review deserve wider recognition. First, the evidence is strong, consistent, and persuasive that CVD risk factor prevention and treatment are associated with lower rates of CVD. Promotion of cardiovascular health is needed throughout the life course, including in early life, to establish lifelong healthy eating, exercise, weight control, and avoidance of tobacco.8 There are no universally effective solutions to accomplish this, but certain principles apply. Recommended dietary patterns focus on meals high in vegetables, fruit, whole grains, seafood, legumes, and nuts; moderate in low-fat and nonfat dairy products; lower in red and processed meat, foods and beverages containing added sugar, and refined grains. These dietary factors can and should be emphasized at both the population-wide level and the individual-patient level. Physical activity must be encouraged in children and adults and emphasize a regular and consistent commitment to daily exercise habits. Research findings support the need to begin interventions in preschool children, involve the family, and continue lifelong.9 More extensive recommendations are readily available.10
Second, the guideline addresses the challenges that remain in treating and controlling risk factors in the clinical setting. Nonetheless, risk factor control in the clinical setting begins with risk assessment, aims at targeting all risk factors above ideal levels, and moves patients in measured steps toward more ideal cardiovascular health. Additional extensive guidance on this is also readily available.4 Better methods of treating CVD risk are needed, and these are complementary to the need for population-wide public health approaches directed at everyone.11
Corresponding Author: Philip Greenland, MD, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, 14th Floor, Chicago, IL 60611 (firstname.lastname@example.org).
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Greenland P, Fuster V. Cardiovascular Risk Factor Control for All. JAMA. 2017;318(2):130-131. doi:10.1001/jama.2017.7648