In November 2020, the United States Preventive Services Task Force (USPSTF) released an updated recommendation regarding behavioral counselling to prevent cardiovascular disease (CVD) in adults. The recommendation states that healthcare providers should offer or refer individuals 18 years or older, with known CVD risk factors (e.g., hypertension or elevated blood pressure or dyslipidemia), to behavioral counseling interventions to promote a healthy diet and physical activity. In the summary statement, it was noted that overall, “Behavioral counseling on healthy eating and appropriate physical activity is an effective intervention and has a moderate net effect in reducing risk of cardiovascular disease.” These recommendations were published in JAMA (November 24, 2020 Volume 324, Number 20) with associated editorial comment, and determined based on a review of the available evidence of the effect of counseling adults on physical activity and a healthy diet.
The USPSTF recommended that the behavioral counseling interventions combine counseling on a healthy diet and physical activity and are usually intensive, with multiple contacts that include either individual or group counseling sessions over extended periods. Interventions usually involved a median of 12 contacts, with an estimated 6 hours of contact time over 6 to 18 months. Interventions typically involved some 1-on-1 time with an interventionist and include motivational interviewing and behavioral change techniques such as goal setting, problem solving, and self-monitoring. Physicians, as well as a wide range of specially trained professionals, including nurses, registered dietitians, nutritionists, exercise specialists, physical therapists, masters- and doctoral-level counselors trained in behavioral methods, and lifestyle coaches, can deliver these interventions.
Common dietary counseling advice included reductions in saturated fats, sodium, and sweets/sugars and increased consumption of fruits, vegetables, and whole grains. The Dietary Approaches to Stop Hypertension (DASH) diet, low-sodium diet, and the Mediterranean diet were commonly recommended. Physical activity counseling focused on achieving 90 to 180 minutes per week of moderate to vigorous activity. Providing specific recommendations regarding exercise leads to a better chance of those counseled reaching the activity goal.
Since this USPSTF recommendation was given a grade of B, the Affordable Care Act requires that commercial health insurance plans provide benefits for, and require no cost sharing for, these preventive services. The previous recommendation released in 2014 was also given a grade B, and this update reinforces the effectiveness of behavioral counseling on diet and physical activity and its positive effect on health outcomes. For those already giving advice, keep up the good work and consider visiting the USPSTF website to review this recommendation and the many resources available to support you in your efforts to promote positive lifestyle changes. For health care providers specifically, the Exercise is Medicine® website has suggestions for how physicians can code and bill for these services during an office visit and patient handouts to support your physical activity message.
This USPTF recommendation may lead to increased referrals for behavioral counseling to various members of the health care team (dietitians, health coaches, clinical exercise physiologists) as well as community-based exercise specialists. While the impact on insurance reimbursement for exercise specialists is unclear, as they have not yet attained the status of qualified health care professional (QHP), this is an exciting step in the right direction. Exercise professionals may also want to consider becoming certified health and wellness coaches to increase their versatility and value to the health care team.
Dr. Joseph Ihm is a sports medicine physician at the Shirley Ryan Ability Lab at Northwestern Feinberg School of Medicine in Chicago, Illinois and serves on the EIM Clinical Practice Committee.
Dr. Liz Joy is the Senior Medical Director for Wellness and Nutrition at Intermountain Healthcare, Past President of the American College of Sports Medicine and serves on the Exercise is Medicine Clinical Practice and Governance Committees.
