USPSTF Updated Guidelines on Behavioral Counseling for CVD Prevention, Plus Expert Interview

A recent issue of JAMA includes a new recommendation statement by the US Preventive Services Task Force (USPSTF) regarding behavioral lifestyle counseling for the prevention of cardiovascular disease (CVD) in adults without obesity or known CV risk factors such as hypertension, abnormal blood glucose levels or diabetes, and dyslipidemia.¹ The guideline is an update to a similar guideline published in 2012.²

In the United States, CVD is the top cause of mortality, with an estimated 2200 CVD-related deaths each day.^3,4 Noting the reduced rates of CV morbidity and mortality in adults who follow national guidelines for physical activity and healthy eating, USPSTF reviewed 88 trials of interventions promoting these behaviors in adults (N=121,190) without known risk factors and a body mass index (BMI) of 18.5 kg/m² to 30 kg/m². According to the researchers, each of these interventions “were judged to be either feasible for delivery in a primary care setting or referable from a primary care setting to community resources.”

The USPSTF concluded that the benefit of behavioral counseling for CVD prevention in this particular population is positive, albeit small. Although they found no direct evidence that counseling led to decreased CVD or mortality rates, they did observe sustained improvements in systolic and diastolic blood pressure, low-density lipoprotein cholesterol (LDL-C), BMI, and waist circumference. Healthful behaviors such as increased produce consumption, reduced salt and calorie intake, and increased physical activity also improved.

“Individuals who do not have obesity or risk factors for CVD and want to make behavioral changes may be [the] most likely to benefit from behavioral counseling,” Task Force vice chair Sue Curry, PhD, interim executive vice president and provost of the University of Iowa in Iowa City said in an interview with Cardiology Advisor. These interventions may include print- or web-based materials, often in combination with face-to-face individual or group counseling.  

“Counseling can be done by primary care clinicians, health educators, behavioral health specialists, nutritionists or dietitians, exercise specialists, and coaches,” Dr Curry added. Appropriate options, including referral to an outside specialist when indicated, should be discussed by the patient and physician.

To get a cardiologist’s perspective on the recommendations, Cardiology Advisor also interviewed Erin D. Michos, MD, MHS, FACC, FAHA, an associate professor of medicine and epidemiology, and associate director of preventive cardiology at Johns Hopkins School of Medicine in Baltimore, Maryland.

Cardiology Advisor: What are your thoughts about the updated recommendations?

Dr Michos: The statement only gave a “C” recommendation to behavioral counseling in patients without obesity or CVD risk factors, which means it can be offered to selected patients depending on individual circumstances, but I do it for every patient. I spend time at each visit with every patient addressing lifestyle changes because I think it is important, even for patients without obesity or CVD risk factors. Maintenance of ideal CV health and primordial prevention is critical. Even the presence of a single major risk factor in middle age is associated with increased lifetime risk of CVD and shorter survival compared with patients whose risk factors are optimal.⁵

Cardiology Advisor: Do you agree with the USPSTF’s determination that there is only a small benefit to behavioral counseling for CVD prevention in this population? 

Dr Michos: The immediate health benefits of behavioral counseling may appear to be small, but the risks are negligible. We have nothing to lose by providing this counseling, and when this is done consistently in the broader US and global populations these small gains can have a huge impact. This is the classic Rose paradox of prevention: the majority of cases of CVD will develop in individuals who previously appeared to be at low or moderate risk, because the number of people at high predicted risk is actually small. So, only counseling individuals at high risk results in missed opportunities for prevention.

Guidelines such as the USPSTF statements are heavily weighted by randomized clinical trials, [which can be] expensive and impractical for something like disease prevention in low-risk individuals, and may take decades of follow-up to determine the impact of interventions. Most of the studies reviewed by the USPSTF were short in duration. Sometimes best judgment based on observational studies has to suffice, and I see absolutely little downside to counseling everyone about lifestyle changes.

Cardiology Advisor: What might such interventions in your practice include?

Dr Michos: Just like simple office counseling on smoking cessation by healthcare providers has been shown to improve quit rates,⁶ I believe that if clinicians frequently and regularly address healthy diet and physical activity at every patient encounter this will trend toward increased adoption of favorable lifestyle changes. In the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins, we use an ABCDE approach to operationalize counseling on prevention at every patient encounter: A, assessment of risk; B, blood pressure management; C, cigarette/tobacco cessation; D, Diet; and E, exercise counseling.⁷

In my conversations with patients about diet and physical activity, I follow the same 5 A’s used in smoking cessation counseling:  Ask, Advise, Assess, Assist, and Arrange.

I think physicians could use better training in counseling patients on lifestyle, such as incorporating techniques of motivational interviewing. Just paternalistic lecturing to a patient on what they should be doing is probably not helpful.

I also think it is important for clinicians to practice what they preach or their advice will not carry as much weight. The most common response I get from patients is that they are “too busy” to exercise, so I share my own tips as a working mother with a busy full-time career as an academic cardiologist. One tip I include is to plan and prep the week’s healthy family menus every Sunday night so there is no need to grab fast food on the way home after work. Another is to plan exercise time with friends and family so that I am less likely to skip workouts.

Those are just my tips for healthy living, which may not work for everyone. Patients should be encouraged to do what works for them. Clinical behavioral counseling should be provided in conjunction with community-based interventions. 

Cardiology Advisor: Who do you refer patients to for more intensive behavioral counseling? 

Dr Michos: For high-risk patients such as patients with established CVD or risk factors, our group has a nurse practitioner who sees patients independently, usually for follow-up visits, who reinforces the ABC’s of prevention. For patients with diabetes, I encourage formal outside nutrition counseling. And for eligible patients with established CVD and heart failure, I am a huge proponent of cardiac rehab services.

But this USPSTF document is about behavioral lifestyle counseling for adults without CVD risk factors or obesity, who usually do not have insurance coverage for such counseling. It is just the right thing to do. [We need to emphasize] primordial prevention and promotion of ideal CV health. 

Disclosures: Aside from travel reimbursement and honoraria for USPSTF meeting participation, no relevant conflicts are reported.

Reference

1. US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2017;318(2):167-174. doi:10.1001/jama.2017.7171
2. US Preventive Services Task Force. Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):367-371. doi:10.7326/0003-4819-157-5-201209040-00486
3. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics. Deaths and mortality. www.cdc.gov/nchs/fastats/deaths.htm. Accessed July 25, 2017.
4. Mozaffarian D, Benjamin EJ, Go AS, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee. Heart disease and stroke statistics — 2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38-e360. doi:10.1161/CIR.0000000000000350
5. Berry JD, Dyer A, Cai X, et al. Lifetime risks of cardiovascular disease. N Engl J Med. 2012;366(4):321-329.
6. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;(2):CD000165. doi:10.1002/14651858.CD000165
7. Hsu S, Ton VK, Dominique Ashen M, et al. A clinician’s guide to the ABCs of cardiovascular disease prevention: the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative. Clin Cardiol. 2013;36(7):383-393. doi:10.1002/clc.22137