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USPSTF Continues to Back Behavioral Intervention to Cut CVD Risk


Adults with risk factors for cardiovascular disease (CVD) should be offered or referred for behavioral counseling to promote a healthy diet and physical activity, the US Preventive Services Task Force (USPSTF) says in an updated recommendation statement. This recommendation is of grade B.

The updated USPSTF statement is largely in line with its 2014 recommendation, although it does not address adults with impaired glucose tolerance or type 2 diabetes mellitus because recommendations for this population are presented in a separate document.

“Also, in the prior 2014 recommendation, the population was defined as overweight or obese, with additional CVD risk factors. With this go-round, we did not have overweight-obesity as a requirement, although a lot of the participants in the trials we looked at did have elevated BMI [body mass index],” task force member Martha Kubik, PhD, RN, George Mason University, Fairfax, Virginia, told Medscape Medical News.

The updated recommendation for behavioral interventions applies to adults with known hypertension, dyslipidemia, and mixed or multiple risk factors, such as metabolic syndrome or an estimated 10-year CVD risk of ≥7.5%.

The updated recommendation was published online November 24 in JAMA. It is accompanied by an article that reviews the evidence for it.

Lower Risk for CVD Events

The task force reviewed 94 randomized controlled trials that assessed behavioral counseling interventions to improve diet and physical activity in 52,174 adults with CVD risk factors. Fifty-two trials were carried forward from the prior review, and 42 were new additions.

Behavioral counseling interventions involved a median of 6 contact hours and 12 sessions over the course of 12 months and varied in format and dietary recommendations.

“No single optimal or representative intervention was identified; a wide range of behavioral counselling approaches improved health profiles,” the task force says.

Overall, medium-contact (31 to 360 min) and high-contact (>360 min) behavioral interventions targeting diet and physical activity were effective in reducing CVD events (pooled relative risk, 0.80; 95% CI, 0.73 – 0.87).

This translates to a number needed to treat of 100 (95% CI, 74 – 154) to prevent one CVD event, assuming a baseline rate of 5%. Population risks of 7.5% and 10% translate to numbers needed to treat of 67 (95% CI, 49 – 103) and 50 (95% CI, 37 – 77), respectively, the task force says.

Behavioral interventions were also associated with small but statistically significant reductions in levels of blood pressure, low-density lipoproteins, fasting glucose, and adiposity, which were continuously measured at 12 to 24 months’ follow-up. The interventions were assosciated “with little to no risk of serious harm,” the task force says.

Implementation Challenges

Kubik said it’s “important for patients and healthcare providers to be aware that we have a base of literature that actually supports that these interventions are effective in reducing cardiovascular disease.

“We want providers to assess CVD risk, recognize the benefit of behavioral interventions, and then be in the position either to provide it within the primary care practice setting or refer outside,” said Kubik.

The authors of an editorial in JAMA say the evidence in support of optimizing dietary patterns and physical activity to promote CV health is “robust, rigorous, and spans the life course from in utero to older adulthood.

“Yet effective translation of these available data from randomized clinical trials to implementation in clinics, communities, and individuals is lacking,” write Sadiya Khan, MD, and Philip Greenland, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

“Since health behaviors (healthy as well as unhealthy) often cluster together, whereby adults who consume healthier diets also often engage in regular physical activity, a comprehensive approach to cardiovascular health promotion may be best suited to all populations, including adults with or without established risk factors,” the editorialists say.

“Future research is needed on how to personalize health behavior interventions at the individual level in conjunction with population-based interventions to equitably reduce premature mortality,” they conclude.

The research was funded by the Agency for Healthcare Research and Quality and the US Department of Health and Human Services. The task force members and editorialists have disclosed no relevant financial relationships.

JAMA. Published online November 24, 2020. Recommendations, Full text; Evidence report, Full text; Editorial

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