Behavioral counseling focused on diet and exercise can provide a "small but potentially important" benefit to stave off heart disease among healthy adults who do not have cardiovascular (CVD) risk factors, according to a new U.S. Preventive Services Task Force (USPSTF) recommendation published Tuesday in JAMA.
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The recommendation updates the panel's 2012 guidelines, which provided similar guidance. The updated recommendation is based on a systematic review of new evidence published since the last recommendation, including 38 additional clinical trials.
USPSTF in the new recommendation said that behavioral counseling can lead to healthful behaviors, such as fruit and vegetable consumption, and small—but potentially important—improvements in blood pressure, body mass index (BMI), low-density lipoprotein cholesterol levels, and waist circumference among healthy adults who do not have CVD risk factors. The panel found "adequate evidence" that the behavioral counseling was associated with little to no harm, but said there is "inadequate direct evidence that behavioral counseling interventions lead to a reduction in mortality or CVD rates."
As such, the panel assigned behavioral counseling a "C recommendation," indicating there is "at least moderate certainty that the net benefit [of the service] is small," and that it could be recommended for some individuals "based on professional judgment and patient preferences." Under the Affordable Care Act, insurers are required to cover preventive services that receive a "B" grade or higher from USPSTF without cost-sharing.
The panel advised clinicians to "understand the evidence but individualize decision making to the specific patient or situation," as some patients, such as those who are interested in making behavioral changes, may be more likely to benefit from such counselling.
The new recommendation does not apply to individuals with obesity, CVD risks—such as hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes—or those who are underweight, USPSTF said.
Valentin Fuster, of Icahn School of Medicine at Mount Sinai, and Philip Greenland, of Northwestern University, in an accompanying editorial said the guideline should "not be regarded as anything less than full endorsement of the importance of control of CVD risk factors," noting that the guideline says "all persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and appropriate physical activity."
However, Christopher Dowrick and Simon Capewell, both of the University of Liverpool in England, in a separate accompanying editorial wrote that the "downstream preventive activities," such as behavioral counseling, "consistently achieve a smaller community health benefit than interventions aimed further upstream (for instance, smoke-free legislation … or regulations eliminating dietary trans-fats)." They added, "These comprehensive, policy-based interventions tend to be more powerful, more rapid, and cost-saving" (Phend, MedPage Today, 7/11; Seaman, Reuters, 7/11; Greenland/Fuster, JAMA, Capewell/Dowrick, JAMA, 7/11; USPSTF recommendation, 7/11).
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