Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: US Preventive Services Task Force Recommendation Statement

Importance  Cardiovascular disease (CVD), which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the US. A large proportion of CVD cases can be prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet. Adults who adhere to national guidelines for a healthy diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not; however, most US adults do not consume healthy diets or engage in physical activity at recommended levels.

Objective  To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the benefits and harms of behavioral counseling interventions to promote healthy behaviors in adults without CVD risk factors.

Population  Adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose or glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater.

Evidence Assessment  The USPSTF concludes with moderate certainty that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors.

Recommendation  The USPSTF recommends that clinicians individualize the decision to offer or refer adults without CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. (C recommendation)

See the Summary of Recommendation Figure.

Cardiovascular disease (CVD), which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the US.^1-3 By 2035, nearly half of US adults are anticipated to have some form of CVD.⁴ A large proportion of CVD cases can be prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet.^2,4 Adults who adhere to national guidelines for a healthy diet⁵ and physical activity⁶ have lower rates of cardiovascular morbidity and mortality than those who do not; however, many US adults do not consume healthy diets or engage in physical activity at recommended levels.^7,8 All persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and physical activity.¹

Important disparities in diet and physical activity exist across the US population.^7-9 Non-Hispanic Black adults report consuming lower amounts of fruits and vegetables than White adults.^8,10 Persons of lower socioeconomic status report less consumption of fruits and vegetables and lower levels of physical activity than those of higher socioeconomic status.^10-12 Adults with lower educational attainment report exercising less than those with higher educational attainment.¹³ Race is often a proxy for exposure to systemic racism, a known source of inequities in social determinants of health.^14,15 Social determinants of health and systemic racism contribute to differences in healthy diet and physical activity by influencing healthy food availability and physical activity barriers and opportunities.^7,8,16,17 For example, while obstacles to pedestrian walking exist across US racial and ethnic groups and income levels,¹⁶ Hispanic/Latino adults and non-Hispanic Black adults report more barriers (eg, animals or crime) to safe walking than White adults.¹⁸

The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors.

See Table 1 for more information on the USPSTF recommendation rationale and assessment and the eFigure in the Supplement for information on the recommendation grade. See the Figure for a summary of the recommendation for clinicians. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.¹⁹

This recommendation applies to adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose or glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater. While obesity is a risk factor for CVD, a separate recommendation statement addresses individuals with a body mass index (BMI) of 30 or greater (calculated as weight in kilograms divided by the square of height in meters).²⁰

Behavioral interventions to reduce CVD risk in adults with known modifiable risk factors (ie, hypertension or dyslipidemia) and weight management interventions are addressed in separate USPSTF recommendations.^20,21 See Table 2 for a summary of current and related USPSTF recommendations on CVD prevention.

The term “healthy diet” is defined as a balance and variety of foods and beverages that assist an individual in achieving and maintaining a healthy weight, supporting health, and preventing disease. As recommended by the US Department of Health and Human Services and the US Department of Agriculture, a healthy diet includes increased consumption of fruits, vegetables, whole grains, fat-free or low-fat dairy, lean proteins, and oils and limited consumption of foods and beverages with high sodium levels, saturated or trans fats, and added sugars.⁵ Additionally, a healthy diet should limit consumption of alcoholic beverages.⁵

Physical activity is broadly defined as any bodily activity that enhances or maintains overall health and physical fitness. The US Department of Health and Human Services recommends that adults 18 years or older engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity per week in addition to engaging in strengthening activities at least twice per week.⁶

The USPSTF recommends selectively offering or providing behavioral counseling interventions to patients based on clinician professional judgment and patient preferences.¹⁹ Behavioral counseling interventions may promote physical activity, healthy diet, reducing sedentary time, or some combination thereof. Common dietary counseling advice promotes increased consumption of fruits, vegetables, and fiber; reduced consumption of saturated fats, sodium, and sugar-sweetened beverages; or both.¹ Patient-tailored approaches to enhance skills with reading food labels, preparing healthy meals, and recognizing appropriate caloric intake and portion size are often used.¹ Physical activity counseling often encourages patients to gradually increase aerobic activity (walking is often emphasized) to achieve at least 150 minutes (2 hours and 30 minutes) per week of equivalent moderate-intensity activity.¹ Reducing sedentary time aims to limit time spent engaging in low-energy behaviors while awake such as sitting or reclining while watching television or using a computer.¹

Primary care clinicians can deliver in-person behavioral counseling interventions or refer patients to other settings. Interventions can be delivered individually, in a group, or both, with or without follow-up (telephone calls or emails), or delivered remotely through a combination of print materials, telephone calls, technology-based activities, or some combination thereof. Typical counseling techniques include behavioral change techniques such as goal setting, problem solving, and self-monitoring; approaches including motivational interviewing principles or portions of the “5 A’s” model (assess, advise, agree, assist, and arrange) are common. A wide range of specially trained professionals, including but not limited to physicians, nurses, registered dietitians, nutritionists, exercise specialists, physical therapists, master’s- and doctoral-level counselors trained in behavioral methods (eg, psychologists), lifestyle coaches, and community health workers can deliver these interventions. Intensity or interaction time with a clinician may range from 30 minutes to 6 hours over 6 months or longer.¹

In determining whether behavioral counseling interventions are appropriate, patients and clinicians should consider the following.

• Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling.

• Higher-intensity counseling interventions may vary in availability and feasibility in clinical settings.

• Adoption of healthy behavior advice may be increased by tailoring behavioral counseling to consider patient motivations and goals, activity level and ability, circumstances, preferences, and overall health status,²³ as well as availability of healthy eating establishments, grocery stores, parks, sidewalks, bicycle trails, safe/pleasant walking paths close to home or workplace; traffic; public transportation; crime; and pollution levels.^{7,8,10-13,16,24}

Several related tools and resources may help clinicians implement this recommendation and assist with uptake of behavioral counseling in specific communities.

• The Centers for Disease Control and Prevention (CDC) leads Active People, Healthy Nation, a national initiative with a goal of increasing physical activity for 27 million Americans by 2027; resources include strategies to increase physical activity for all, including considerations in persons with disabilities, and tools for action (https://www.cdc.gov/physicalactivity/activepeoplehealthynation/index.html).²⁵

• The CDC and the Centers for Medicare & Medicaid Services co-lead Million Hearts, a national initiative aimed toward preventing 1 million heart attacks and strokes within 5 years (https://millionhearts.hhs.gov/index.html).²⁶

• The Health Equity Resource Toolkit for State Practitioners Addressing Obesity Disparities, provided by the CDC, is available at https://www.cdc.gov/nccdphp/dnpao/health-equity/state-health-equity-toolkit/pdf/toolkit.pdf. A separate website provides information about planning, implementing, and evaluating programs to narrow obesity disparities (https://www.cdc.gov/nccdphp/dnpao/health-equity/state-health-equity-toolkit/index.html).²⁷

• The Community Preventive Services Task Force recommends several community-based interventions to promote a healthy diet (https://www.thecommunityguide.org/topic/nutrition)²⁸ and physical activity (https://www.thecommunityguide.org/topic/physical-activity),²⁹ including community-wide campaigns, social support interventions, school-based interventions, and environmental and policy approaches.

• The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit contains general guidance to assist primary care settings with linking patients to nonmedical support (https://www.ahrq.gov/health-literacy/improve/precautions/tool18.html)³⁰ and making referrals (https://www.ahrq.gov/health-literacy/improve/precautions/tool21.html).³¹

• The US Department of Health and Human Services and the US Department of Agriculture have developed dietary guidelines (https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials)⁵ and physical activity guidelines (https://health.gov/our-work/physical-activity/current-guidelines).⁶ Additional resources to promote the physical activity guidelines are available at https://health.gov/our-work/nutrition-physical-activity/move-your-way-community-resources.³²

The USPSTF has several recommendations for promoting cardiovascular health in adults.

• Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors²¹

• Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults²⁰

• Screening for high blood pressure in adults³³

• Interventions for tobacco smoking cessation in adults, including pregnant persons³⁴

• Aspirin use for the prevention of CVD³⁵

• Statin use for the primary prevention of CVD in adults³⁶

• Screening for prediabetes and type 2 diabetes in adults²²

• Current versions of these and other related USPSTF recommendations are available at https://www.uspreventiveservicestaskforce.org/uspstf/.

In 2017, the USPSTF recommended that primary care professionals individualize the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to promote a healthful diet and physical activity (C recommendation).³⁷ This updated recommendation is consistent with the 2017 recommendation.

The USPSTF commissioned a systematic evidence review^1,38 to update its 2017 recommendation on behavioral counseling to promote a healthy diet and physical activity for CVD prevention in adults without cardiovascular risk factors. The review evaluated the benefits and harms of behavioral counseling interventions to promote healthy behaviors in adults without CVD risk factors. The scope was similar to that of the prior systematic review.

The USPSTF included 113 randomized clinical trials in its review (n = 129 993), most of which were conducted in the US (60 trials).^1,38 All trials reported at least 6 months of follow-up, and many (63 trials) reported 12 months or longer.^1,38 Most trials (73 trials) included men and women.^1,38 The mean age of participants ranged widely, from 18.5 to 79.5 years.^1,38 The mean BMI of trial participants across studies was in the overweight range (27.8).^1,38 Sixty-nine trials reported participant race and ethnicity.^1,38 Of these, most participants were White persons; in 17 trials, Asian persons, Black persons, Hispanic/Latino persons, or Native American/American Indian persons comprised more than two-thirds of participants.^1,38 Most intervention groups focused on physical activity (48.1%), healthy diet (19.1%), or both (32.5%). Delivery mode varied widely; 52.9% of trials included at least 1 in-person counseling session, whereas 42.7% of trials involved sessions delivered completely remotely.

The USPSTF found sufficient evidence that behavioral counseling interventions for a healthy diet, physical activity, or both were associated with modest increases in physical activity levels and some improvements in dietary health behaviors.^1,38 The analysis included 109 trials (n = 125 878) that reported the effect of behavioral counseling interventions on diet, physical activity, or sedentary health behaviors.^1,38 On average, participants of physical activity interventions (87 trials) increased physical activity by approximately 33 minutes per week (95% CI, 21.9 to 44.2) and had higher odds of meeting physical activity recommendations after 6 to 12 months (pooled odds ratio, 1.41 [95% CI, 1.18 to 1.67]) compared with participants in the control group.^1,38 Participants of healthy diet interventions (45 trials) increased fruit and vegetable intake (mean difference, 1.11 servings per day [95% CI, 0.41 to 1.81]) and fiber intake (standardized mean difference, 0.24 [95% CI, 0.05 to 0.43]) and decreased saturated fat intake (standardized mean difference, −0.53 [95% CI, −0.78 to −0.27]) compared with participants in the control group.^1,38 The USPSTF found little evidence of the effectiveness of sedentary behavior interventions.^1,38 Overall, sedentary behavior interventions did not demonstrate statistically significant differences in sedentary behaviors in participants compared with control groups.^1,38

The USPSTF found sufficient evidence that behavioral counseling interventions for a healthy diet, physical activity, or both were associated with lower blood pressure, low-density lipoprotein cholesterol (LDL-C), and adiposity measures (BMI, weight, and waist circumference) after 6 to 12 months.^1,38 The analysis included 43 trials (n = 77 965) reporting the effect of healthy diet and physical activity behavioral counseling interventions on intermediate outcomes such as blood pressure or adiposity measures.^1,38 Diet and physical activity interventions were associated with lower systolic blood pressure (−0.8 mm Hg [95% CI, −1.30 to −0.31]), diastolic blood pressure (−0.42 mm Hg [95% CI, −080 to −0.04]), LDL-C level (−2.20 mg/dL [95% CI, −3.80 to −0.60]), and adiposity-related outcomes such as weight (−1.07 kg [95% CI, −1.62 to −0.52]), BMI (−0.32 [95% CI, −0.51 to −0.13]), and waist circumference (−0.81 cm [95% CI, −1.32 to −0.30]).^1,38 Generally, high-intensity interventions (>360 minutes) were associated with greater changes in intermediate outcomes, specifically lower LDL-C and adiposity measures.^1,38

Observational evidence from large prospective studies and individual participant data meta-analysis of prospective cohort studies demonstrates that small changes in intermediate outcomes (ie, lower blood pressure) were associated with small reductions in risk of cardiovascular-related mortality and all-cause mortality.^39,40

The USPSTF found little direct evidence on the effectiveness of behavioral counseling interventions on all-cause mortality, CVD-related mortality, CVD events (such as myocardial infarction or stroke), or quality of life.^1,38 In studies, CVD-related fatal and nonfatal events were rare, limiting robust analysis, with few group differences.^1,38 A variety of self-reported quality of life measures were reported in 15 trials; group differences were generally very small and of unclear clinical significance.^1,38

Of the 113 trials reviewed by the USPSTF, only 23 (n = 12 452) specifically reported on harms or lack of harms of behavioral counseling interventions.^1,38 Overall, harms were rare, and there were no statistically significant differences reported between intervention participants and control groups on any adverse events, serious adverse events, musculoskeletal injuries, or falls.^1,38

A draft version of this recommendation statement was posted for public comment on the USPSTF website from January 18, 2022, to February 14, 2022. Several respondents requested additional tools to aid clinicians and patients; in response, the USPSTF added materials containing strategies to encourage healthy lifestyles and updated language in the recommendation statement. The recommendation statement includes links to resources (eg, The Community Guide) that may assist primary care linkages needed to implement this recommendation. In addition, the USPSTF calls for additional research into effective primary care–community connections and clinical training to support delivering in-person behavioral counseling and referring patients for behavior counseling in other settings.

Comments requested additional detail to identify patients who could benefit from behavioral counseling; the USPSTF recommends that professional judgment and patient preference guide clinician decision-making for behavioral counseling interventions in persons without known risk factors. The role of risk assessment in the delivery of behavioral counseling is addressed in a separate recommendation for persons with known CVD risk.²¹ Comments requested clarification on which types of professionals could provide behavioral counseling. The USPSTF recognizes and clarified that multiple types of professionals, both medical and nonmedical, can deliver behavioral counseling interventions. Comments also requested more detail to identify barriers to healthy lifestyle engagement in certain populations; the USPSTF calls for more research on evidenced-based interventions that can benefit all potential users.

The USPSTF identified several gaps in the evidence where more research is needed.

• Studies should enroll enough participants from populations disproportionately affected by CVD to understand the benefit of physical activity and dietary behavioral counseling interventions in these populations. Culturally appropriate and tailored intervention research may help reduce disparities related to cardiovascular health.

• Future research should elucidate best practices for clinicians and patients to navigate known environmental and structural barriers to healthy diet and physical activity toward effective interventions that support persons of all ages and abilities. Primary care–feasible interventions with strong linkages between clinical and community settings may help effectively implement healthy behavior interventions.

• Future research should identify best practices to improve clinician skills in delivering in-person behavioral counseling and referring patients to other settings for behavioral counseling.

• Future research should ensure that patient-reported quality of life outcomes related to cardiovascular health are consistently measured and reported.

• Future research should validate and standardize dietary intake and physical activity instruments in collection and reporting. Additionally, standardization of digital interventions, apps, and supports could benefit implementation of remote or in-person behavioral counseling interventions.

• Future research should design and test interventions to reduce sedentary behavior. The recent increase in working from home during the COVID-19 pandemic may present an opportunity to perform research on effective interventions that reduce sedentary time.

• Future research that is adequately powered and of sufficient follow-up duration is needed in patients without known CVD risk.

The American College of Cardiology and the American Heart Association (AHA) guidelines to prevent CVD emphasize a team-based approach, with consideration of the social determinants of health that affect patients to guide clinical decisions. The guidelines recommend healthy diet consumption along with 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity physical activity.⁴¹ The American College of Sports Medicine and the AHA recommend that clinicians provide behavioral counseling on physical activity to all adults regardless of chronic conditions or risk factors. In 2018, they co-launched the Exercise is Medicine initiative, calling for clinicians to assess and promote physical activity for all patients.⁴² The American Academy of Family Physicians supports the 2017 USPSTF recommendation on this topic.⁴³ The AHA recommends physical activity assessment and promotion in health care settings for all adult patients to prevent CVD.⁴⁴

Corresponding Author: Carol M. Mangione, MD, MSPH, David Geffen School of Medicine, University of California, Los Angeles, 10940 Wilshire Blvd, Ste 700, Los Angeles, CA 90024 (chair@uspstf.net).

Accepted for Publication: June 13, 2022.

The US Preventive Services Task Force (USPSTF) members: Carol M. Mangione, MD, MSPH; Michael J. Barry, MD; Wanda K. Nicholson, MD, MPH, MBA; Michael Cabana, MD, MA, MPH; Tumaini Rucker Coker, MD, MBA; Karina W. Davidson, PhD, MASc; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Martha Kubik, PhD, RN; Li Li, MD, PhD, MPH; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; John B. Wong, MD.

Affiliations of The US Preventive Services Task Force (USPSTF) members: University of California, Los Angeles (Mangione); Harvard Medical School, Boston, Massachusetts (Barry); University of North Carolina at Chapel Hill (Nicholson, Donahue); Albert Einstein College of Medicine, New York, New York (Cabana); University of Washington, Seattle (Coker); Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York (Davidson); University of Pittsburgh, Pittsburgh, Pennsylvania (Davis); The University of Texas Health Science Center, San Antonio (Jaén); George Mason University, Fairfax, Virginia (Kubik); University of Virginia, Charlottesville (Li); New York University, New York, New York (Ogedegbe); University of Massachusetts Medical School, Worcester (Pbert); University of Arizona, Tucson (Ruiz); University of Missouri, Columbia (Stevermer); Tufts University School of Medicine, Boston, Massachusetts (Wong).

Author Contributions: Dr Mangione had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The USPSTF members contributed equally to the recommendation statement.

Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank Sheena Harris, MD, MPH, and Justin Mills, MD, MPH (AHRQ), who contributed to the writing of the manuscript, and Lisa Nicolella, MA (AHRQ), who assisted with coordination and editing.

Additional Information: The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. Published by JAMA®—Journal of the American Medical Association under arrangement with the Agency for Healthcare Research and Quality (AHRQ). ©2022 AMA and United States Government, as represented by the Secretary of the Department of Health and Human Services (HHS), by assignment from the members of the United States Preventive Services Task Force (USPSTF). All rights reserved.