USPSTF Guidelines: Counsel Healthy Adults on CVD Risk Reduction

Troy Brown, RN

July 11, 2017

Behavioral counseling provides positive but modest benefits for preventing cardiovascular disease in adults without risk factors, a final recommendation from the US Preventive Services Task Force states. The updated statement appears online today in JAMA and on the task force website.

The statement updates the previous 2012 statement, which made similar recommendations. It is based on a new systematic evidence review that included 50 trials from the 2012 review and 38 new trials.

"The Task Force encourages primary care clinicians to talk to their patients about eating healthy and physical activity, and if they are interested and motivated to make lifestyle changes, offer and refer them to counseling," task force vice chair Susan Curry, PhD, said in a task force news release. Dr Curry is interim executive vice president and provost of the University of Iowa, where she also serves as a distinguished professor of health management and policy in the College of Public Health.

This is a C grade recommendation, which means that for most of those without signs or symptoms there is likely only a small benefit to the action and clinicians should offer the service "only if other considerations support the offering or providing the service in an individual patient."

This recommendation is intended for adults aged 18 years and older without risk factors including obesity, underweight, hypertension, hyperlipidemia, diabetes, or abnormal blood glucose.

Behavioral counseling interventions are usually conducted face-to-face or by telephone during multiple sessions, sometimes lasting for several months and including print and electronic materials. These interventions are more intensive than a single conversation with a healthcare provider and can include educational sessions, personalized care plans, problem-solving techniques, and feedback. Health insurance does not always cover behavioral counseling interventions.

"This recommendation complements separate Task Force recommendations for people at increased risk, which recommend behavioral counseling for all high-risk patients," task force member Carol M. Mangione, MD, MSPH, said in the news release. Dr Mangione is the Barbara A. Levey, MD, and Gerald S. Levey, MD, endowed chair in medicine at the David Geffen School of Medicine at the University of California, Los Angeles, and professor of public health at the University of California, Los Angeles, Fielding School of Public Health.

An evidence summary, an editorial, and a patient page accompany the recommendation statement in the journal. Two other editorials appear in JAMA Internal Medicine and JAMA Cardiology.

"Upstream" Measures More Effective Than "Downstream" Measures

" 'Upstream' measures such smoke-free legislation may be more effective than 'downstream' measures such as behavioral counseling," Simon Capewell, MD, DSc, from Clinical Epidemiology, and Christopher Dowrick, MD, FRCGP, from Primary Medical Care, both at University of Liverpool, United Kingdom, write in an accompanying editorial published in JAMA Internal Medicine.

"Extensive evidence suggests that downstream preventive activities targeting individuals (such as behavioral counseling, 1-on-1 personal advice to stop smoking or take exercise, health education, or prescribing primary prevention medications) consistently achieve a smaller community health benefit than interventions aimed further upstream (for instance, smoke-free legislation, tobacco taxes, alcohol minimum pricing, or regulations eliminating dietary trans-fats)," they write. "Indeed, these comprehensive, policy-based interventions tend to be more powerful, more rapid, and cost-saving. Furthermore, these population wide policies are also more equitable, tending to reduce disparities, while individual interventions tend to increase disparities."

"Useful examples come from recent trends in the United States. For instance, smoking prevalence in men has fallen from approximately 80% immediately after World War II to less than 20% today. This success in tobacco control demonstrates how comprehensive strategies have used upstream policies addressing the '3 As': (1) affordability (taxes and price hikes), (2) acceptability (notably, smoke-free laws and zero marketing), and (3) availability (eg, removing vending machines, licensing retailers, verifying customers' age). Conversely, behavioral counseling in isolation has played only a modest role in tobacco control, as in alcohol reduction," Dr Capewell and Dr Dowrick explain.

Multipronged Approach Needed

An approach that uses both a public health approach and an intervention targeted toward high-risk individuals may be most effective, Philip Greenland, MD, from the Department of Preventive Medicine and the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and senior editor, JAMA; and Valentin Fuster, MD, PhD, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, and Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain, write in an editorial published in JAMA.

"Control of CVD risk factors traditionally has involved 2 complementary approaches — a general plan for everyone (public health approach) and a targeted intervention for people with specific risk factors (the clinical or high-risk approach)," they explain.

"The public health approach is based on the well-known principle that a small shift in risk to better control for the entire population can achieve as much, or greater, effect in disease prevention than targeted interventions focusing only on specific subsets of the population. This concept was popularized in 1985 by Rose and has become known as the 'Rose Prevention Paradox,' " Dr Greenland and Dr Fuster write. "Both approaches are widely accepted, and both are needed for maximal control of CVD. The need to consider prevention efforts for entire populations, while also treating specific patients in clinical settings, provides important context for interpreting the US Preventive Services Task Force recommendation statement guideline and the accompanying evidence summary in this issue of JAMA."

Motivation to Change May Not Be Necessary

A final editorialist questions whether a patient must be motivated at all before they can make a positive health change.

"The [task force's] recent recommendation includes a suggestion that individuals who are interested in and ready to make behavioral changes may be most likely to benefit from behavioral counseling. The basis for this suggestion is that effects could not be examined in those who did not enroll in trials, and enrollees may have been highly motivated, as evidenced by retention of 85% over 12 months of follow-up," Bonnie Spring, PhD, Northwestern University Feinberg School of Medicine, Preventive Medicine, Chicago, Illinois, writes in JAMA Cardiology. "An important caution is warranted, however, before concluding that motivational readiness to change is a necessary prerequisite for the success of behavioral interventions. First, because motivation and change readiness were not compared between trial enrollees and non-enrollees, we lack direct evidence that study participants were atypically highly motivated."

Dr Spring continues, "Second, and more importantly, we assumed at one time that a high level of motivation was required for a smoking cessation treatment to produce benefit. On the contrary, it now appears that smoking cessation treatments can work well even for those who express disinterest or active antagonism to the prospect of giving up cigarettes. In addition to risking recruitment of an unrepresentative, non–real-world sample, including only study candidates who are keenly enthusiastic to be in treatment also withholds potential benefit from the population subgroups whose socioeconomic burdens and comorbidities place them in greatest need of help."

The authors and editorialists have disclosed no relevant financial relationships.

JAMA. Published online July 11, 2017. Article

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