The decline in age-adjusted mortality rates attributed to cardiovascular disease (CVD) has been characterized as the success story of the past four decades, worldwide. In the United States, a similar downtick has been recorded since 1978. The rapid progress in the fields of prevention and management may be responsible for this promising landscape in the CVD spectrum (1). Nevertheless, CVD still remains the largest single contributor to global mortality with up to date evidence indicating abatement in the rate of the aforementioned mortality decline (1). In the United States, CVDs are on the top of the disability rank possessing a large economic burden for the public health system; the total direct medical costs between 2012 and 2030 are projected to increase from $396 to $918 billion (2).
As clearly demonstrated by the Non-Communicable Diseases Global Monitoring Framework, effective primary prevention strategies are demanded to meet these challenges. In 2012, the American Heart Association revealed a set of Strategic Impact Goals targeting “by 2020, to improve the cardiovascular health of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%” (2). That is when a new term was introduced to address this target, “the ideal cardiovascular health”; defined as the absence of CVD manifestation with the simultaneous presence of optimal levels in seven lifestyle and clinical metrics (i.e., Life’s Simple 7) (2). The vast majority of Americans is far from meeting the current nutritional and physical activity recommendations while they present a high prevalence in major CVD risk factors including abnormal lipid and glucose profile, increased blood pressure and abdominal obesity (3). Findings from the INTERHEART large scale case-control study suggested that these modifiable risk factors accounted for more than 90% of the myocardial infarction risk (4); at the same time, there is unambiguous evidence that prudent dietary habits and physically active lifestyle are inversely associated with the aforementioned clinical manifestations (5-7).
Following the need for well-documented low-cost practices in the primary CVD prevention spectrum, an updated evidence report and systematic review was published in JAMA by the US Preventive Services Task Force (USPSTF) accompanied by a recommendation statement guideline for primary health care professionals. The authors conducted a systematic review with the hitherto randomized clinical trials (RCTs) examined behavioral counseling (i.e., healthy diet, increased physical activity, decreased sedentary time or a combination of these) applied to non-obese adults without known hypertension, dyslipidemia, and diabetes/prediabetes. Four distinctive outcomes in relation to intervention were discussed; CVD morbidity and/or mortality (i.e., direct outcomes), clinical CVD risk factors (i.e., intermediate outcomes), lifestyle modifications (i.e., intervention efficiency) and potential harmful effects. Eighty-eight RCTs met the inclusion criteria, most of which were conducted in the United States with a 6- to 12-month follow-up. An overall improvement in dietary habits and physical activity status was observed after the intervention. However, it is important to mention that in case of sparse trials with longer follow-up period the effect of dietary counseling was attenuated whilst as for physical activity counseling, results were more favorable in RCTs where all participants had a suboptimal physical activity level at baseline. Regarding the intermediate cardiac health outcomes, the pooled analysis highlighted a significant yet slight or modest improvement in blood pressure, blood lipids profile (i.e., low density lipoprotein, total cholesterol) and adiposity measurements (i.e., body mass index, waist circumference). Most importantly, a dose-response association was suggested by the authors with the aforementioned outcomes being more evident ranking from low- to medium- and high-intensity interventions. The available findings regarding the independent-of-physical-activity sedentary behavior were scarce and generally less consistent. Besides the overall beneficial effect of behavioral counseling on intermediate cardiac health outcomes and lifestyle modification, no statistically and most importantly, clinically significant outcomes were observed regarding CVD morbidity, mortality and health related quality of life. As speculated by the contributors of the present work, the short-term follow-up period along with the heterogeneity of the applied behavioral interventions could justify this observation.
A range of complementary life course strategies has been suggested in the literature at individual, population or health care system level, with a dual purpose; to improve cardiac health of individuals with unhealthy lifestyle and clinical comorbidities in their medical history and to support the retention of an optimal risk factor profile in apparently healthy individuals (2). The USPSTF addresses a specific target group (i.e., low CVD risk subjects) providing a guideline to primary health care professionals on an individual-centered basis; “to individualize the decision to offer or refer low CVD risk adults to behavioral counseling to promote a healthful diet and physical activity” (Grade C).
According to World Health Organization, 80% of CVD morbidity and mortality rates would be prevented on the grounds of adherence to health-related behaviors such as optimal dietary habits and physical activity status. However, this should not be the finishing point. In the present and other relevant systematic reviews performed by USPSTF, only modest short-term benefits were highlighted and solely in case of intermediate health outcomes (8). Thereby, translating the knowledge into actual practice is always remaining a complex issue in CVD prevention lifestyle-centered strategies to achieve outcomes with a high clinical importance (9). To meet the challenge of lifestyle modification, the nature of the whole applied intervention seems detrimental. In this context, efficient psychological and behavioral theoretical principles should be taken into serious consideration (10). Most importantly, the appropriate—for—the target group delivery mode, schedule, nature of counseling and intensity of the whole procedure should be selected with consciousness (10,11). The readiness to change is another fundamental parameter in lifestyle interventions which can determine their progress and efficiency; also, implied in the present guideline provided by the USPSTF. This is the reason for which patients at high-risk with clinical symptoms and signs are more likely to benefit from behavioral counseling (11). Hence, when it comes to lifestyle interventions applied to apparently healthy individuals, application of motivational techniques is strongly suggested to achieve a long-term compliance (12,13).
Behavioral counseling of healthy nutrition and physical activity seems modestly beneficial in primary CVD prevention. Therefore, it is justifiably recommended in primary health care professionals. However, the strategies and techniques through which this recommendation will be put into the real-world setting needs a better clarification. In a global society with finite healthcare resources, the effective integration of low cost individual-centered lifestyle modification approaches seems a compelling strategy to meet the challenges in the CVD prevention spectrum. Primary health care practitioners should be encouraged to incorporate them in their daily clinical practice. Consequently, the need for a new generation of studies with tailor-made behavioral lifestyle counseling is imperative to achieve more strong, tangible and long-term outcomes.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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