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Basic Health Advice of Little Help

Primary care doctors should be selective in offering lifestyle-change behavioral programs aimed at preventing cardiovascular disease (CVD) to healthy patients who have unhealthy habits, the U.S. Preventive Services Task Force recommended.

“Although the correlation among healthful diet, physical activity, and the incidence of CVD is strong, existing evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small,” according to Virginia Moyer, MD, MPH, and other USPSTF members writing online in Annals of Internal Medicine.

“Clinicians may choose to selectively counsel patients rather than incorporate counseling into the care of all adults in the general population,” they concluded.

The recommendations applied to what the task force called “medium- or high-intensity behavioral counseling interventions in the primary care setting,” not to simple, brief advice to exercise more and cut back on ice cream.

Medium-intensity programs were those that involved from 31 minutes to 6 hours of direct patient contact. Interventions with more than 6 hours of contact were considered high-intensity.

Although such intensive counseling is unlikely to cause direct harm to patients, spending such time with patients who end up with no benefit represents a “lost opportunity to provide other services that have a greater health effect,” the task force argued.

In deciding which patients would be the best candidates for medium- to high-intensity counseling interventions, clinicians should consider “other risk factors for CVD, a patient’s readiness for change, social support and community resources that support behavioral change, and other healthcare and preventive service priorities,” Moyer and colleagues wrote.

With most adults in the U.S. overweight or obese, and with large numbers getting little to no regular exercise, the benefits of a healthy diet and physical activity in reducing cardiovascular disease risk are not in dispute.

But in patients without a formal diagnosis of hypertension, diabetes, hyperlipidemia, or overt cardiovascular disease, “there is adequate evidence that the benefits of medium- to high-intensity behavioral counseling interventions to improve diet and increase physical activity are small to moderate,” the task force found after reviewing the literature.

Only a few programs, such as those directed at cutting salt intake, appeared to have a clinically significant effect on risk factors and outcomes. These did succeed in reducing blood pressure and subsequent cardiovascular events in patients with baseline diastolic pressure of 80 to 89 mm Hg, according to a 2010 review.

Moyer and colleagues also pointed to the Women’s Health Initiative Dietary Modification Trial, in which women were randomized to low-fat or conventional diets and followed for 8 years. Blood pressure and plasma glucose levels were reduced in the first year with the low-fat diet, but the improvement faded over time.

“More important, no differences occurred in major CVD events or mortality after 8 years,” the task force observed.

But few medium-intensity and no high-intensity programs had been studied in the primary care setting, the group observed, suggesting that such interventions probably are not practical in routine primary care.

In arguing against such interventions as routine care for relatively healthy patients, the USPSTF noted that it has issued other recommendations addressing lifestyle counseling for patients with clearer cardiovascular risks.

For example, it has recommended intensive behavioral counseling for patients “with hyperlipidemia and other known risk factors,” as well as screening for hypertension in all adults and for lipid disorders in those with certain factors.

The group has also urged screening for obesity and intensive behavioral counseling for obese patients.

Whether medium- to high-intensity lifestyle interventions would be valuable for otherwise healthy people remains a valid research topic, Moyer and colleagues emphasized, especially for younger adults.

The task force also called for more studies of the combined effects of clinical and community-based programs, as well as on whether small physiologic changes can produce significant improvements in long-term clinical outcomes.