Doctors, Individualize Care for Patients Without Heart Risks

Clinicians should decide on a case-by-case basis whether adults without risk factors for cardiovascular disease (CVD) should receive behavioral health counseling to promote a healthier diet and more exercise, according to new guidance from the US Preventive Services Task Force (USPSTF).

The recommendations, published Tuesday in the Journal of the American Medical Association, are based on a review of the scientific literature. The researchers found that behavioral counseling can lead to small improvements in a healthy person's risk for CVD.

"The key here is that these interventions can be helpful for some individuals who don't have cardiovascular disease risk factors, producing small benefits in physical activity and diet as well as blood pressure, cholesterol, BMI [body mass index], and weight," Lori Pbert, PhD, associate chief of the Division of Preventive and Behavioral Medicine, who is a member of the task force, told Medscape Medical News. "That's the main message. These are small improvements but they're meaningful."

The recommendation focuses on adults aged 18 years and older who do not have risk factors for CVD, such as smoking, obesity, and diabetes. The task force in 2020 said clinicians should offer adults with risk factors for CVD behavioral counseling or make referrals to outside programs.

The latest iteration applies to an estimated 12.2% of US adults who do not already have conditions such as elevated blood pressure and dyslipidemia.

If primary care clinicians do provide counseling on their own, recommendations could include promoting increased consumption of fruits, vegetables, and whole grains and encouraging patients to gradually increase moderate-intensity activity to 2.5 hours or vigorous activity to 75 minutes a week.

While clinicians can still use their discretion to decide whether patients without risk factors would benefit from counseling, the recommendation carries an evidence grade of C, which means providers can't seek reimbursement for their time in delivering services. The Affordable Care Act requires private insurers to cover without cost sharing all preventive services for which there is "strong scientific evidence" of health benefits and that have either a grade of A or B, according to the USPSTF.

"We're not covering these preventive measures as much as we are paying for diabetes medications or are paying for obesity-related surgeries," Anne Thorndike, MD, immediate past chair of the American Heart Association's Nutrition Committee and associate professor at Harvard Medical School, said. "Those things are, of course, very important, and I'm not saying we shouldn't pay for them, but I'd like to see us get to a place where we don't have to pay for as many of those because we're actually putting more dollars up front for people to get the behavioral interventions that they need to not get that place."

The analysis included 109 trials with 125,878 participants. Those who engaged in the targeted exercise intervention increased their physical activity by approximately 33 minutes per week (95% CI, 21.9 – 44.2) and were 41% more likely to meet recommended levels of physical activity after 6 to 12 months than participants in control groups, which varied across the studies in the meta-analysis.

Those who received healthy diet interventions (45 trials) increased their intake of fruit and vegetables by a mean difference of 1.11 servings a day, minimally increased their intake of fiber, and decreased their intake of saturated fat.

Findings from 77,965 participants in 43 trials showed that the combination of diet and physical interventions was linked to decreases in blood pressure, low-density lipoprotein cholesterol level, BMI, weight, and waist circumference.

A Focus on Those With Risk Factors

The updated recommendations put a renewed focus on the majority of Americans with risk factors for cardiovascular problems. Clinicians should provide counseling or refer patients on the basis of USPSTF 2020 recommendations. Only about 1 in 4 patients in the United States who have diabetes receive counseling on diet or exercise, according to a 2019 study published in the American Journal of Preventive Medicine.

Providers need better tools, such as dietary and physical activity screeners, resources, and training, to successfully offer behavioral counseling, according to Thorndike.

"I think that we could take advantage of more group-based interventions that could be done in primary care. This doesn't all have to take place on a one-on-one visit in the physician's office," she said. New strategies, technology, and resources could reduce time pressure in individual visits while still connecting patients and providers, she added.

However, the success of counseling may hinge on a patient's readiness to make lifestyle changes.

"Primary care clinicians are critical in terms of starting this conversation and initiating the counseling and, in addition, referring to resources that can do this more intensive intervention," Pbert said. "Those are interested and ready to make changes are most likely to benefit from counseling."

The study was funded by the Agency for Healthcare Research and Quality, which supports the operations of the USPSTF. Pbert has disclosed no relevant financial relationships. One task force member has received funding from the National Institutes of Health on other research.

JAMA. Published online July 26. 2022. Full text

Michelle Dendy Washmuth is a freelance writer living in Colorado.

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Image 1: Harvard Medical School

Image 2: US Preventive Services Task Force

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Cite this: Doctors, Individualize Care for Patients Without Heart Risks - Medscape - Jul 29, 2022.