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The U.S. Preventive Services Task Force (USPSTF) recommended lifestyle counseling for cardiovascular disease (CVD) prevention in adults with certain risk factors regardless of their weight.

Behavioral counseling interventions promoting healthy diet and exercise have a moderate net CVD benefit in adults at risk due to known hypertension, dyslipidemia, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater, the Task Force concluded with moderate certainty after a systematic review.

"The USPSTF recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity," wrote Alex Krist, MD, MPH, of Virginia Commonwealth University, Richmond, and colleagues in .

This B recommendation from Krist's group finalized the draft update released in the spring.

With the new statement, the USPSTF dropped the stipulation for people with overweight and from its of lifestyle counseling. It also excluded adults with diabetes, a population slated to be addressed later in a separate USPSTF statement.

"While this recommendation is focused on adults with CVD risk factors, it is broadly relevant as this represents at least one-third of adults in the general population in the U.S.," commented Sadiya Khan, MD, MSc, and JAMA editor Philip Greenland, MD, both of Northwestern University Feinberg School of Medicine in Chicago.

Data supporting optimizing dietary patterns and physical activity to promote cardiovascular health are robust, rigorous, and span the life course from in utero to older adulthood, Khan and Greenland wrote in an accompanying editorial.

"Yet effective translation of these available data from randomized clinical trials to implementation in clinics, communities, and individuals is lacking," according to them. "Future research is needed on how to personalize health behavior interventions at the individual level in conjunction with population-based interventions to equitably reduce premature mortality."

For the updated recommendation, Krist and colleagues relied on a of 94 behavioral counseling intervention studies.

Nearly all of the studies addressed diet, with or without physical activity, and varied widely in format and dietary recommendations; some also included medication management. Interventions involved a median of six contact hours and twelve sessions over the course of 12 months.

Overall, behavioral interventions were associated with a 20% reduction in cardiovascular risk (pooled RR 0.80, 95% CI 0.73-0.87), according to authors of the systematic review, led by Elizabeth O'Connor, PhD, of Kaiser Permanente Northwest in Portland, Oregon.

Small but significant reductions were observed in blood pressure, LDL cholesterol, fasting glucose level, and adiposity levels at 12 to 24 months of follow-up.

As for safety, there was generally no signal of increased serious adverse events, hospitalizations, or musculoskeletal injuries with the tested interventions.

Khan and Greenland highlighted the question of who should be delivering behavioral counseling for promotion of healthy diet and exercise.

"Often, clinicians are at the front line of discussing behavioral changes with patients, yet the majority of medical training is focused on disease detection based on diagnostic testing and interpretation. In addition to mastery of skills needed for behavioral counseling, time constraints and limited reimbursement for behavioral counseling often result in superficial recommendations to pursue 'healthy' lifestyle behaviors," they lamented.

The editorialists also pointed to unresolved questions on how to develop culturally salient interventions that tackle race-based and place-based disparities in heart health in the U.S.

Lifestyle counseling for CVD prevention in adults without cardiovascular risk factors holds a from the USPSTF.