A new guideline from the US Preventive Services Task Force (USPSTF) published in JAMA1 advises primary care clinicians about whether they should offer behavioral counseling to promote healthful diet and physical activity to adults without traditional risk factors for cardiovascular disease (CVD) (hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes). The practice of offering behavioral counseling to these low-risk patients received a C recommendation. This means that the USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences; there is at least moderate certainty that the net benefit is small.1 Because the reviewers did not find grade B evidence of benefit, the provision of diet and activity counseling will not be routinely covered by private insurers. Instead, the new guideline advises clinicians to judge whether to provide behavioral counseling or whether to refer individual patients to receive it by making a shared decision that integrates the patient’s preferences, values, and circumstances.
The recommendation to individualize decisions about offering diet and activity counseling is based on a review of 88 trials,2 38 of which are new since publication of the systematic review that grounded the 2012 USPSTF guideline on this topic.3 The reviewers observed small beneficial effects of diet and activity behavioral interventions on the intermediate health outcomes of systolic and diastolic blood pressure, low-density lipoprotein and total cholesterol levels, and adiposity (BMI and waist circumference) and small beneficial effect as well on the CVD risk behaviors of low fruit and vegetable intake, high saturated fat, salt, and calorie intake, and low levels of moderate to vigorous physical activity. Dose-response effects were also found, indicating that an increased intensity of behavioral intervention was associated with greater improvement in intermediate health outcomes. Although no consistent effects of diet and activity counseling were observed on mortality or cardiovascular events, both of these outcomes were rare for the duration of follow-up. No serious adverse events were reported to result from behavioral diet and activity counseling, and other harms (including falls from physical activity intervention) were no greater in the treatment groups than among controls. The absence of evidence of harms coupled with the evidence of modest, statistically significant benefit justifies the USPSTF’s appraisal that all adults, regardless of CVD status, can gain benefit from healthy eating and physical activity behaviors.
Despite the judgment that all adults can potentially benefit, USPSTF reaffirmed its prior recommendation3 that diet and physical activity counseling should be offered only selectively, not routinely as a component of care for all patients.1 The USPSTF’s discretionary guidance regarding behavioral counseling for individuals without traditional CVD risk biomarkers stands in contrast to its stronger (grade B) recommendation (high certainty that the net benefit is moderate; or moderate certainty that the net benefit is moderate to substantial) for provision or referral to intensive behavioral counseling for all patients with obesity (BMI, >30),4 overweight (BMI, 25 to <30) if accompanied by hypertension or hyperlipidemia,5 and even patients with normal weight who have diabetes or abnormal blood glucose levels.6 Importantly, the USPSTF’s guidance to offer diet and activity behavioral intervention only selectively to patients without traditional CVD risk markers also contrasts with that of the American Heart Association (AHA),7,8 the American College of Cardiology,9 the American College of Preventive Medicine,10 and the US Department of Health and Human Services Healthy People 2020,11 who all recommend routine nutritional assessment and physical activity counseling for all adult patients. Likewise, USPSTF’s guidance differs from that of the American College of Sports Medicine12 and the American Medical Association’s “Exercise is Medicine” campaign,13 both of which advocate routine documentation of physical activity as a vital sign and provision of counseling by the physician or a community agency. This recommendation is also endorsed by the Task Force on Community Preventive Services.14
Why does the USPSTF not advise diet and activity intervention for all patients, following what other health professional organizations recommend? One reason may be an important difference between how the USPSTF and the other guideline bodies conceptualize CVD risk. The USPSTF considers adults without known CVD risk factors to be those who lack only hypertension, hyperlipidemia, diabetes, and/or abnormal glucose levels. Other well-established biomarkers (eg, obesity) and behaviors (eg, physical inactivity, poor-quality diet, smoking) that are proven to heighten CVD risk15 may be present, but USPSTF does not count these among the “known” CVD risk factors. In addition to these risk factors being omitted from several risk calculators (eg, Framingham), the USPSTF systematic review team suggested that poor-quality diet and physical inactivity are so prevalent in the population that excluding people who exhibit these behaviors would threaten the generalizability of the systematic review.2 In effect, CVD risk behaviors have become so prevalent that they can be seen as “the new normal,” rather than as warning signs on the pathway toward disease.
The radically different point of view articulated most forcefully in the AHA’s concept of “ideal cardiovascular health”15 is that unhealthful diet and activity behaviors are indeed very prevalent, and they are known CVD risk factors with adverse prognostic effects that rival those of, and are not always entirely explained by, the known biomarkers on the CVD disease pathway.16 Consequently, AHA considers departure from ideal health status on any of its “simple 7” metrics to constitute intervention-worthy CVD risk, with behavioral and biomarker indices weighted as equally important.15 As a consequence, the AHA and other like-minded health professional organizations consider promotion of healthful diet and physical activity to be routinely warranted at most, if not all, clinical encounters. With most adults failing to reach ideal health metrics for physical activity and fewer than 2% achieving ideal status for healthful diet, it can be argued that our health care system would be remiss not to capitalize on any opportunity to promote healthier lifestyles. Also, as the systematic reviewers for USPSTF’s recent guidance noted,2 intervention effects on diet and activity outcomes are larger in magnitude when the sample has unhealthful lifestyle behaviors to begin with. From this perspective, once the presence of physical inactivity and poor diet are understood (legitimately) as known CVD risk factors, greater intervention effects may warrant stronger guidance, enabling the routine practice of behavioral risk reduction intervention to become evidence-based practice policy.
The USPSTF’s recent recommendation1 includes a suggestion that individuals who are interested in and ready to make behavioral changes may be most likely to benefit from behavioral counseling. The basis for this suggestion is that effects could not be examined in those who did not enroll in trials, and enrollees may have been highly motivated, as evidenced by retention of 85% over 12 months of follow-up. An important caution is warranted, however, before concluding that motivational readiness to change is a necessary prerequisite for the success of behavioral interventions. First, because motivation and change readiness were not compared between trial enrollees and nonenrollees, we lack direct evidence that study participants were atypically highly motivated. Second, and more importantly, we assumed at one time that a high level of motivation was required for a smoking cessation treatment to produce benefit. On the contrary, it now appears that smoking cessation treatments can work well even for those who express disinterest or active antagonism to the prospect of giving up cigarettes.17 In addition to risking recruitment of an unrepresentative, non–real-world sample, including only study candidates who are keenly enthusiastic to be in treatment also withholds potential benefit from the population subgroups whose socioeconomic burdens and comorbidities place them in greatest need of help.
Considerable coordination and effort will be needed to implement the critical aspect of evidence-based cardiovascular risk reduction that addresses healthful change in diet, physical activity, and other lifestyle behaviors. The connective digital infrastructure afforded by the electronic health record, patient portal, and mobile tools holds the potential to reduce burden and foster effective collaboration by linking medical professionals with patients and with other professionals who have needed behavioral expertise. Actually integrating the provision of biologically and behaviorally targeted care could, in turn, ease the systemic challenge of infusing health promotion into our current system of “sickness care” and motivate a larger portion of the population to strive for fuller, healthier lives.
Corresponding Author: Bonnie Spring, PhD, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (email@example.com).
Published Online: July 11, 2017. doi:10.1001/jamacardio.2017.2568
Conflict of Interest Disclosures: Dr Spring has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.
Spring B. Healthful Physical Activity and Diet Promotion—For the Many or the Few?. JAMA Cardiol. Published online July 11, 2017. doi:10.1001/jamacardio.2017.2568