June 25, 2012 — Clinicians should selectively counsel patients about healthy lifestyle choices, rather than incorporate counseling into the care of all adults in the general population, according to updated guidelines from the US Preventive Services Task Force (USPSTF).
According to Sue Curry, PhD, from the University of Iowa, Iowa City, one of the task force members, the updated guidance does not preclude discussions about healthy behaviors as part of routine office visits; rather, the decision to offer intensive recommendations geared toward behavior modification can be made on a case-by-case basis.
"These guidelines concern people who do not have heart disease and do not have known risk factors," Dr. Curry stressed. "Everybody, regardless of their [cardiovascular disease (CVD)] risk, can benefit from good nutrition and regular physical activity, and those are messages that can be provided during routine primary care. This recommendation is about whether and how to pick up on that message for people who do not have CVD and do not have risk actors: Would you refer them? Or try to engage them on any kind of behavioral counseling for dietary changes or physical activity in addition to reinforcing the importance of a healthful diet and regular physical activity? And the evidence suggests that while we don't recommend against it, we don't need to recommend it routinely.... This recommendation says that clinicians may choose to selectively provide this service, rather than incorporating it into the routine care of all adult patients."
The new recommendations were published online June 25 in the Annals of Internal Medicine by Virginia A. Moyer, MD, MPH, from the Baylor College of Medicine, Houston, Texas, and colleagues on behalf of the USPSTF. They update the 2003 and 2002 USPSTF statements on behavioral counseling to promote a healthful diet and physical activity in adults without preexisting CVD or its risk factors (hypertension, hyperlipidemia, or diabetes). Based on a review of new evidence, the USPSTF evaluated counseling interventions that address physical activity or a healthful diet and that are appropriate for the primary care setting. Relevant outcomes were modification of self-reported behaviors; intermediate physiologic outcomes such as improved lipid profiles, blood pressure, weight, body mass index, and glucose tolerance; and cardiovascular morbidity and mortality.
This evidence review showed a strong correlation of healthful diet and physical activity with the incidence of CVD. However, there appears to be only a small health benefit to starting behavioral counseling in the primary care setting to promote a healthful diet and physical activity.
Evidence is adequate that in the target population, there are small to moderate benefits of medium- to high-intensity behavioral counseling interventions on improving diet and increasing physical activity. Evidence is also adequate that there are small, short-term (up to 1 year) benefits of medium- to high-intensity behavioral counseling interventions to improve intermediate health outcomes.
However, evidence is inadequate that medium- to high-intensity behavioral counseling interventions directly reduce rates of mortality or CVD events.
Factors that could affect the potential efficacy of behavioral counseling in a specific patient include other risk factors for CVD, the patient's motivation to change, social support and community resources facilitating behavioral change, and other healthcare and preventive service priorities.
Potential harms of behavioral counseling in primary care might include a lost opportunity to offer other services with a greater health benefit. Evidence is adequate that intense physical activity is only rarely associated with adverse cardiovascular events, but none of the studies reviewed was designed to detect adverse effects of interventions targeting diet. The conclusion of the USPSTF was that behavioral counseling interventions are associated with little to no potential harms.
Overall, the USPSTF concluded with moderate certainty that in the primary care setting, medium- or high-intensity behavioral counseling interventions to promote a healthful diet and physical activity have a small net benefit in the target population. Therefore, they issued a grade C recommendation that clinicians may choose to selectively counsel patients rather than incorporate counseling into the care of all adults in the general population.
"This recommendation replaces the USPSTF's previous separate recommendations (both I statements) on behavioral counseling to promote a healthful diet (2003) and physical activity (2002) in adults without preexisting CVD or its risk factors," the statement authors write. "The 2003 recommendation on dietary counseling included a positive (grade B) recommendation for counseling adults with risk factors for CVD; however, the current recommendation does not address this population. The current recommendation statement differs from the previous statements in that the USPSTF now finds sufficient evidence to conclude with moderate certainty that medium- to high-intensity counseling has a small net benefit on health behaviors and outcomes in adults without CVD, hypertension, hyperlipidemia, or diabetes."
Full disclosure information is available on the journal's Web site .
Ann Int Med. Published online June 25, 2012. Full text
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Cite this: USPSTF Updates 'Lifestyle Counseling' Guidance - Medscape - Jun 25, 2012.