USPSTF Recommendations for Behavioral Counseling in Adults With Cardiovascular Disease Risk Factors

Abstract

The United States Preventive Services Task Force (USPSTF) has released new recommendations for adults with known cardiovascular disease (CVD) risk factors 1 and an associated systematic literature review. 2 The recommendations encourage medical practitioners to offer or refer adults with CVD risk factors to behavioral counseling interventions to promote healthy diet and physical activity (B recommendation). 1,2 Notable changes from the 2014 recommendations are that recommendations are extended to patients who are not overweight or obese (individuals who are overweight or obese are covered in other recommendations), CVD risk factors are expanded to include patients with elevated blood pressure and a 10-year CVD risk of 7.5% or greater, research pertaining to patients with impaired fasting glucose or diabetes is no longer included in the review but discussed in separate recommendation statements, and it is no longer specified that behavioral interventions should be intensive. 1 In addition, suggestions for implementation now state that behavioral counseling can be provided using media-based interventions. The systematic literature review 2 concluded that behavioral interventions produced a moderate net benefit, and resulted in lower incidence of CVD events; reductions in blood pressure, lower total cholesterol, and low-density lipoprotein cholesterol; and weight loss. Barriers to Implementation There are several barriers to implementing these USPSTF recommendations 1,2 in clinical settings. Owing to the expanded definition of CVD risk factors in this update, 1,2 behavioral counseling is recommended for a large proportion of, perhaps most, US adults. 3 Delivering behavioral counseling interventions to this large population would require substantial health systems change. Of 120 interventions in 94 studies included in the USPSTF commissioned review, 2 7 interventions (5.8%) were low intensity (ie, Յ30 minutes of contact), 59 interventions (49.2%) were medium intensity (ie, 31-360 minutes), and 54 interventions (45.0%) were high intensity (ie, >360 minutes). While some low-intensity interventions were effective, the most effective interventions in the studies reviewed included at least monthly contacts with patients over a period of 4 months or longer. 2 Interventions of this intensity may not be feasible in primary care settings owing to time constraints, increased care requirements of an aging population, competing clinical demands, and impending workforce shortages, and suboptimal geographic distribution of primary care clinicians. 4-6 While patients may want their primary care clinicians to provide lifestyle counseling, many primary care clinicians may not be familiar or experienced with communication techniques needed to engage and sustain behavior change in their patients 4,5,7 ; therefore, it is critical that behavioral counseling interventions are available to patients outside of primary care visits. As mentioned in the USPTF recommendations, 1 behavioral counseling services can be provided by nurses, register...

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