USPSTF Sets Diet and Exercise Recommendations for Adults Without Cardiovascular Risks

Carol M. Mangione, MD, MSPH

The US Preventive Services Task Force (USPSTF) has issued a recommendation that clinicians individualize their decision to refer adults without risk factors for cardiovascular disease (CVD) to behavior counseling interventions that promote healthier diet and physical activity habits.

The recommendation is consistent with a 2017 guidance released by the USPSTF, and entails counseling intervention strategies that may help to curb the increasing prevalence of adult CVD in the US. It was given a “C” grade for strength of recommendation.

Led by Carol M. Mangione, MD, MSPH, of the David Geffen School of Medicine at UCLA, the recommendation authors emphasized the importance of addressing modifiable risk factors for CVD when setting the new guidance for potential prevention.

“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,” they wrote. “All persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and physical activity.”

Their recommendation population included adults ≥18 years old without known CVD risk factors, including hypertension; elevated blood pressure; dyslipidemia; impaired fasting glucose or glucose tolerance; metabolic syndrome; or an estimated 10-year CVD risk of ≥7.5%. Obesity, a common CVD risk factor among US adults, was not included due to a separate USPSTF recommendation addressing persons with a BMI ≥30.

Mangione and colleagues defined a healthy diet 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.” They cited recommendations from the US Department of Health & Human Services (HHS) and US Department of Agriculture (DA) when including fruits, vegetables, whole grains, fat-free or low-fat dairy, lean proteins and oils, as well as limited sodium, trans fats, added sugars, and alcoholic beverages.

Physical activity, meanwhile, featured a broader definition per the HHS: ≥150 minutes of moderate-intensity or ≥75 minutes of vigorous-intensity aerobic physical activity weekly, plus ≥2 strengthening activities weekly.

The newest USPSTF recommendation includes 5 implementation strategies for clinicians who may initiate behavioral counseling strategies for CVD prevention in adults:

1. Dietary counseling advice to promote the inclusion of the healthier foods recommended by the HHS and DA, as well as reduction of harmful foods.
2. Physical activity counseling advice that may encourage patients to gradually increase aerobic exercise such as weekly walks to span the duration recommended by the HHS.
3. Dispersal of educational literature and use of telemedicine or group counseling practices to establish a follow-up with patients receiving such recommendations.
4. Implementation of individual goal-setting and standards for self-monitoring, with emphasis on establishing the “5 A’s” model with patients: assess, advise, agree, assist, and arrange.
5. Referral to specialty-trained colleagues or other relevant health care providers to help deliver these dietary and exercise interventions.

The recommendation authors wrote that both patients and clinicians should consider factors such as whether persons are ready to make such behavioral changes and would benefit from them, as well as whether the tailorability and feasibility of such interventions reflect the agenda of patients.

Dariush Mozaffarian, MD, DrPH, of the Friedman School of Nutrition Science and Policy at Tufts University, noted in an editorial accompanying the recommendation that the targeted group of adults without CVD risk factors is in fact, a small minority of the US population: an estimated 12.2%, based on 2017-18 national data.

“The recommendation to individualize the decision to offer or refer adults to behavioral counseling interventions applies to the relatively small proportion of US adults without obesity, hypertension, dyslipidemia, prediabetes, or diabetes,” Mozaffarian wrote. “For everyone else—the great majority of US adults—clinicians should provide or refer them to intensive behavioral counseling.”

Speaking long-term, Mozaffarian wrote that health systems could consider incorporating diet and physical activity promotion for its patients through improved clinician education, health record screening and tracking, evidence-based behavioral counseling, referrals to appropriate services, and corresponding quality-of-care standards reimbursements.

“These actions could help increase the provision of and referral to intensive behavioral counseling to improve diet quality and physical activity,” Mozaffarian said. “To increase the likelihood that such efforts also could reduce health disparities, these strategies should be combined with health systems approaches to address social determinants of health, such as food insecurity, housing, transportation, employment, and education.”

The USPSTF recommendations were published online to JAMA.