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People at risk for cardiovascular disease (CVD) should receive behavioral counseling promoting a healthy diet and physical activity, according to .

Harms of counseling interventions promoting a healthy diet and exercise are expected to be small. Therefore, the "USPSTF concluded with moderate certainty that behavioral health interventions have a moderate net benefit on CVD risk in adults at increased risk for CVD," authors wrote in a draft statement to be posted online Tuesday.

Their grade B recommendation marks a slight change from from the group.

Back then, the USPSTF recommended intensive behavioral counseling interventions for overweight and obese adult patients with known CVD risk factors, including hypertension, dyslipidemia, impaired fasting glucose or glucose intolerance, and metabolic syndrome.

The new recommendation targets a group not already covered by an existing USPSTF recommendation: adults with known hypertension or elevated blood pressure, elevated lipid levels or dyslipidemia, and mixed or multiple risk factors (e.g., metabolic syndrome or estimated 10-year CVD risk of ≥7.5%).

"These new guidelines now broaden the group of patients for whom behavioral health counseling is recommended to include not just those with overweight or obesity, but the broader group with individual CVD risk factors such as hypertension, irrespective of whether they are overweight," commented Ian Kronish, MD, MPH, of Columbia University Irving Medical Center in New York City.

"It also incorporates a risk-based approach to identifying candidates for behavioral screening that is consistent with hypertension and lipid guidelines. So overall, this new guideline is a nice update in that it is more closely aligned with other CVD prevention recommendations, and this alignment should facilitate adoption," said Kronish, who was not part of the USPSTF team.

Existing recommendations cover ; and and those .

Backing the recommendation was a systematic review of the literature that included 94 trials of mostly overweight or obese cohorts.

Study participants had an estimated 6 hours of contact over 12 months. Most behavioral counseling interventions took place in primary care settings and were most often delivered by non-physicians. Behavior change techniques included goal setting, active use of self-monitoring, and addressing barriers related to diet, physical activity, or weight change. Sessions were to be done in-person or over the phone or a web portal.

Pooled data from these trials suggested lower risks of major adverse outcomes:

• Cardiovascular events: RR 0.80 (95% CI 0.73-0.87)
• MI: RR 0.85 (95% CI 0.70-1.02)
• Stroke: RR 0.52 (95% CI 0.25-1.10)

"By many accounts, behavioral or lifestyle factors account for 50% or more of the variation in cardiovascular disease risk. Unfortunately, thus far, based on the evidence synthesis for this USPSTF recommendation update, the magnitude of benefit of most of the behavioral interventions remains relatively small. There is still a pressing need for research into more potent interventions," Kronish emphasized.

USPSTF members also cautioned that very few trials in the analysis had sufficient sample size and follow-up to assess the effect on CVD events such as MI, stroke, and mortality. In addition, reporting of behavioral outcomes was highly variable and often incomplete across studies.

"In the meantime, however, this recommendation shows that there is at least moderate-strength evidence in support of our existing, at least moderate intensity interventions, and these remain underutilized," according to Kronish.

"It is clear that making changes in diet and physical activity is beneficial for reducing CV risk. Unfortunately, too many people have poor dietary habits and do not engage in sufficient amounts of physical activity. So the question is how do you get people to make these changes?" commented Kerry Stewart, EdD, of Johns Hopkins University School of Medicine in Baltimore, who was not involved with the USPSTF group.

"What does not work very well is when clinicians give advice like 'eat more healthy' or 'exercise more.' This is where comes into play by using evidenced-based methods to motivate and support lifestyle change," Stewart said.

The draft recommendation statement is open for public comment through June 8, 2020.

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