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Editorial
July 11, 2017

Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Risk FactorsIs Behavioral Counselling Necessary?

Author Affiliations
  • 1Clinical Epidemiology, University of Liverpool, United Kingdom
  • 2Primary Medical Care, University of Liverpool, United Kingdom
JAMA Intern Med. Published online July 11, 2017. doi:10.1001/jamainternmed.2017.1979

In 2014, the US Preventive Services Task Force (USPSTF) issued advice focused on individuals with elevated cardiovascular risk factors.1 They have now focused on “healthy” adults who do not have hypertension, dyslipidemia, obesity, abnormal blood glucose, or diabetes. The current issue of JAMA contains the latest USPSTF recommendation, which states as follows: “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, 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. Individuals who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling. (C recommendation)”2 (The generalized language for a C recommendation is as follows: 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.)2

A healthful diet and physical activity are worthy targets. Indeed, poor diet alone accounts for at least 40% of all deaths and disability-adjusted life years.3 However, the USPSTF statement raises a number of issues. These concerns might include intervention heterogeneity, “real-life” effectiveness, potential benefits and harms, and the distraction from other, more effective prevention strategies for these low-risk individuals, and indeed for the wider community.

A Diversity of Behavioral Change Interventions

The USPSTF reviewed over 120 distinct and diverse counseling interventions focusing on promoting a healthful diet, physical activity, or both.4,5 A third involved low-intensity interventions (mailings, print or web-based materials). Half of the interventions were medium intensity (0.5 to 6 hours of contact time), and a fifth were high intensity (>6 hours of contact time), commonly including face-to-face individual or group counselling with follow-up by telephone, email, or text, and typically lasting around 6 months. The main behavioral change techniques were diverse, and variably included goal setting and planning, monitoring and feedback, motivational interviewing, addressing barriers to change, increasing social support, and general education or advice. These counseling interventions were variously delivered by primary care clinicians, health educators, behavioral health specialists, nutritionists, dieticians, exercise specialists, or lay coaches.4,5 The heterogeneity of these interventions was thus further increased.

Efficacy, Effectiveness, and Sustainability

The trials were not powered to report on mortality; however, over 30 (mostly medium- or high-intensity trials) reported on intermediate outcomes. Results from the “better quality” trials were selected and then pooled to demonstrate modest improvements averaging a 1-kg weight loss, a 1.3–mm Hg decrease in systolic blood pressure, and a 2.6-mg/dL decrease in low-density lipoprotein cholesterol.4,5 Behavioral outcomes, mostly self-reported,4,5 demonstrated an apparent dose-response effect that the USPSTF highlighted.2 However, skeptics might suggest that while modest efficacy was probably demonstrated in optimal conditions in selected trials, real-world effectiveness, and hence cost-effectiveness, remains less certain.

Furthermore, the absolute reductions in nonfatal and fatal events achieved by such behavioral counseling interventions are likely to be even more modest because the probability of early death in these low-risk, healthy adults is already much lower than in adults with unhealthy behaviors.6

The evidence on sustainability was also limited because few trials went beyond 12 months. Relapse of dietary and activity behaviors and regaining lost weight are all likely, particularly given the low perceived risks and low perceived benefits to the individual. Prochaska’s Stages of Change model7 usefully proposes the stages of precontemplation, contemplation, preparation, action, maintenance—and relapse. Relapse is more likely if the person is stressed but less likely if new learning is placed in familiar context, includes retrieval cues, is leveraged with positive human emotions, and, crucially, is linked into societal norms.8 Our social, economic, and physical environment can thus powerfully support healthful behaviors—or undermine them. Furthermore, an excessive focus on individual behavior also risks obscuring those very powerful social determinants of ill health.9,10 Might focusing on behavioral counseling of individuals to generate modest gains likewise distract attention from other, more comprehensive and effective approaches?

The Effectiveness Hierarchy: “Upstream” vs “Downstream” Interventions

Extensive evidence suggests that downstream preventive activities targeting individuals (such as behavioral counseling, 1-on-1 personal advice to stop smoking or take exercise, health education, or prescribing primary prevention medications) consistently achieve a smaller community health benefit than interventions aimed further upstream (for instance, smoke-free legislation, tobacco taxes, alcohol minimum pricing, or regulations eliminating dietary trans-fats).10 Indeed, these comprehensive, policy-based interventions tend to be more powerful, more rapid, and cost-saving.10,11 Furthermore, these population-wide policies are also more equitable, tending to reduce disparities, while individual interventions tend to increase disparities.12

Useful examples come from recent trends in the United States. For instance, smoking prevalence in men has fallen from approximately 80% immediately after World War II to less than 20% today.10 This success in tobacco control demonstrates how comprehensive strategies have used upstream policies addressing the “3 As”: (1) affordability (taxes and price hikes), (2) acceptability (notably, smoke-free laws and zero marketing), and (3) availability (eg, removing vending machines, licensing retailers, verifying customers’ age).10 Conversely, behavioral counseling in isolation has played only a modest role in tobacco control, as in alcohol reduction.13

These principles are likely to be equally relevant when considering soda or junk food. For example, Brandt et al14 report the recent success of progressive policies to eliminate toxic industrial trans-fats from the food eaten by Americans and the potential achievement of substantial mortality reductions.

Adverse Events and Medicalization

The first duty of a physician is to do no harm—primum non nocere. Only 14 of the behavioral-counseling trials reviewed by the USPSTF4,5 reported on adverse events, mostly injuries and falls. None considered medicalization; might engaging healthy persons in behavioral counselling carry the risk of turning them into lifelong “patients”? The World Organisation of Family Doctors (WONCA)15 supports Jamoulle’s concept of quaternary prevention, “actions taken to identify a patient or population at risk of over-medicalisation, and protect them from invasive medical investigations and provide care procedures which are ethically acceptable.”16(p4)

Overdiagnosis and overtreatment carry serious hazards.9 Labeling individuals as being at risk or as having a disease based entirely on biometric analysis can lead to unnecessary fear that undermines health and well-being. In addition to escalating financial and opportunity costs, overtreatment can also lead, paradoxically, to undertreatment, by diverting attention and resources away from those most severely affected. More controversially, should physicians therefore perhaps endorse McCormick’s suggestion that family physicians should encourage their patients to live lives of “modified hedonism”?17(p291)

Conclusions

In conclusion, we paraphrase a recent JAMA editorial by Redberg and Katz18 on the use of statins for primary prevention of cardiovascular disease: Before recommending any intervention that has potential adverse effects, it is incumbent on clinicians to identify evidence that intervention will lead to a better quality of life, or longer life, or both. Given these potential concerns about behavioral counseling in healthy individuals, it is surely in the interests of the medical and wider public communities to instead prioritize upstream policies. Let us create a social environment for our families and friends that supports a heart-healthy diet, regular physical activity, and not smoking.

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Article Information

Corresponding Author: Simon Capewell, MD, DSc, Department of Public Health, Liverpool University, Whelan Bldg, Quadrangle, Liverpool, Merseyside L69 3GB, United Kingdom (capewell@liverpool.ac.uk).

Published Online: July 11, 2017. doi:10.1001/jamainternmed.2017.1979

Conflict of Interest Disclosures: None reported.

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