in progress

Draft Recommendation Statement

Promotion of a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: Behavioral Counseling

January 18, 2022

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This topic is being updated. Please use the link(s) below to see the latest documents available.
  • Update in Progress for Promotion of a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: Behavioral Counseling

Recommendation Summary

Population Recommendation Grade
Adults age 18 years or older without known cardiovascular disease risk factors The USPSTF recommends that clinicians individualize the decision to offer or refer adults without cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. See the "Practice Considerations" section for information on determining which patients may benefit most from this service. C

Additional Information

Tools
Related Resources
  • Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors (Consumer Guide): Draft Recommendation | Link to File

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Cardiovascular disease (CVD), which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the United States.1-3 In 2016, 1 in 3 U.S. adults died of CVD-related disease.4 By 2035, nearly half of U.S. adults are anticipated to have some form of CVD.2 Modifiable risk factors for CVD include smoking, obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet.4 Adults who adhere to national guidelines for a healthy diet5 and physical activity6 have lower rates of cardiovascular morbidity and mortality than those who do not. All persons, regardless of their CVD risk status, can gain health benefits from healthy eating behaviors and physical activity.1

Important disparities in diet and physical activity behaviors exist across the U.S. population. Non-Hispanic Black adults report consuming lower amounts of fruits and vegetables than White adults.1,7 Persons of lower socioeconomic status report lower consumption of fruits and vegetables and lower levels of physical activity than those of higher socioeconomic status.1,7-9 Similarly, adults with lower educational attainment report exercising less than those with higher educational attainment.1,10 Race is often a proxy for systemic racism exposure; systemic racism is a source of inequities in social determinants of health.11,12 Systemic racism and social determinants of health (e.g., socioeconomic status) may directly or indirectly contribute to housing, healthy food availability, transportation, education, and physical environment barriers and opportunities.1,11,12

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The U.S. Preventive Services Task Force (USPSTF) concludes with moderate certainty that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.13

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Patient Population Under Consideration

This recommendation applies to adults age 18 years or older without known CVD risk factors, including hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose/glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater. While obesity is a risk factor for CVD, the evidence review that supports this recommendation statement did not exclude studies that enrolled persons who have overweight or obesity. A separate recommendation statement addresses individuals with a body mass index (BMI) of 30 kg/m2 or greater.14

Interventions to reduce CVD risk in adults with known modifiable risk factors (i.e., hypertension or dyslipidemia) are addressed in a separate USPSTF recommendation.15 See Table 2 for a summary of current and related USPSTF recommendations on CVD prevention.

Definitions of Healthy Diet and Physical Activity

The term “healthy diet” is defined as a balance and variety of foods and beverages that assist an individual in achieving and maintaining a healthy weight, support health, and prevent disease. As recommended by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture, a healthy diet includes increased consumption of fruits, vegetables, whole grains, fat-free or low-fat dairy, lean proteins, and oils and limited consumption of foods with high sodium levels, saturated or trans fats, and added sugars.5

Physical activity is broadly defined as any bodily activity that enhances or maintains overall health and physical fitness. The U.S. Department of Health and Human Services recommends that adults age 18 years or older engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity per week in addition to engaging in strengthening activities at least twice per week.6

Assessment of Risk

Certain risk factors, including hypertension, obesity, dyslipidemia, and metabolic syndrome can increase a person’s risk for CVD; behavioral counseling on healthy diet and physical activity in persons with cardiovascular risk factors is addressed in a separate recommendation. However, even when these risk factors are absent, eating a healthy diet and participating in physical activity may improve cardiovascular health.

Behavioral Counseling Interventions and Implementation Considerations

Behavioral counseling interventions may promote physical activity, healthy diet, or both. Common dietary counseling advice promotes increased consumption of fruits, vegetables, and fiber; reduced consumption of saturated fats, sodium, and sweets; or both.1 Patient-tailored approaches to enhance skills with reading food labels, preparing healthy meals, and recognizing appropriate caloric intake and portion size are often used.1 Physical activity counseling often encourages patients to gradually increase aerobic activity (walking was often emphasized) to achieve at least 150 minutes per week of moderate to vigorous activity.1

Primary care clinicians can deliver in-person behavioral counseling interventions or refer patients to other settings. Interventions can be delivered individually, in a group, or both, with or without followup (telephone calls or emails), or delivered remotely through a combination of print materials, telephone calls, technology-based activities, or some combination thereof. Typical counseling techniques include motivational interviewing and behavioral change techniques such as goal setting, problem solving, and self-monitoring. A wide range of specially trained professionals, including physicians, nurses, registered dietitians, nutritionists, exercise specialists, physical therapists, masters- and doctoral-level counselors trained in behavioral methods, and lifestyle coaches, can deliver these interventions. Intensity or interaction time with a clinician may range from 30 minutes to 6 hours over 6 months or more.1

In determining whether behavioral counseling interventions are appropriate, patients and clinicians should consider the following.

  • Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling.
  • Higher-intensity counseling interventions may vary in availability and feasibility in clinical settings.
  • Adoption of healthy behavior advice may be increased by tailoring behavioral counseling to consider patient motivations and goals, activity level and ability, circumstances, preferences, and overall health status,16 as well as availability of healthy eating establishments, grocery stores, parks, sidewalks, bicycle trails, safe/pleasant walking paths close to home or workplace, traffic, public transportation, crime, and pollution levels.1,7-10,17

Additional Tools and Resources

There are several related tools and resources that may help clinicians implement this recommendation.

Other Related USPSTF Recommendations

The USPSTF has several recommendations for promoting cardiovascular health in adults.

  • Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors15
  • Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults14
  • Screening for high blood pressure in adults22
  • Interventions for tobacco smoking cessation in adults, including pregnant persons23
  • Aspirin use for the primary prevention of CVD and colorectal cancer24
  • Statin use for the primary prevention of CVD in adults25
  • Screening for prediabetes and type 2 diabetes in adults26

Current versions of these and other related USPSTF recommendations are available at https://www.uspreventiveservicestaskforce.org/uspstf/.

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Scope of Review

The USPSTF commissioned a systematic evidence review1 to update its 2017 recommendation on behavioral counseling to promote a healthy diet and physical activity for CVD prevention in adults without cardiovascular risk factors. The review evaluated the benefits and harms of behavioral counseling interventions to promote healthy behaviors in adults without CVD risk factors. The scope was similar to that of the prior systematic review.

Benefits of Counseling to Change Behavior and Outcomes

The USPSTF included 113 randomized clinical trials in its review (n=129,993), most of which were conducted in the United States (60 trials).1 All trials reported at least 6 months of followup, and many (63 trials) reported 12 months or greater.1 Most trials (73 trials) included men and women.1 The mean age of participants ranged widely from 18.5 to 79.5 years.1 The average BMI of trial participants across studies was in the overweight range, with a BMI of 27.8 kg/m2.1 Sixty nine trials reported participant race and ethnicity.1 Of these, most participants were White persons; in 17 trials, Hispanic/Latino, Black, Asian, or Native American/American Indian persons comprised more than two-thirds of participants.1 Most intervention groups focused on physical activity (48.1%), healthy diet (19.1%), or both (32.5%). Delivery mode varied widely, with half of the trials (52.9%) including at least one in-person counseling session while just under half (42.7%) were delivered completely remotely.

The USPSTF found sufficient evidence that behavioral counseling interventions for a healthy diet, physical activity, or both were modestly associated with increased physical activity levels and some changes in dietary health behaviors.1 The analysis included 109 trials (n=125,878) reporting the effect of behavioral counseling interventions on diet, physical activity, or sedentary health behaviors.1 Compared with controls, participants of physical activity interventions (87 trials) increased physical activity by approximately 33 minutes per week (95% CI, 21.9 to 44.2) and had 41% higher odds of meeting physical activity recommendations after 6 to 12 months (pooled odds ratio, 1.41 [95% CI, 1.18 to 1.67]).1 Participants of healthy diet interventions (45 trials) increased fruit and vegetable intake (mean difference, 1.11 servings per day [95% CI, 0.41 to 1.81]) and fiber intake (standard mean difference, 0.24 [95% CI, 0.05 to 0.43]) and decreased saturated fat intake (standard mean difference, -0.53 [95% CI, -0.78 to -0.27]) compared with controls.1 The USPSTF found little evidence of the effectiveness of sedentary behavior interventions.1 Overall, sedentary behavior interventions did not demonstrate statistically significant differences in sedentary behaviors in participants compared with control groups.1

The USPSTF found sufficient evidence that behavioral counseling interventions for a healthy diet, physical activity, or both were modestly associated with lower blood pressure, low-density lipoprotein (LDL) cholesterol, and adiposity measures (BMI, weight, and waist circumference) after 6 to 12 months.1 The analysis included 43 trials (n=77,965) reporting the effect of healthy diet and physical activity behavioral counseling interventions on intermediate outcomes such as blood pressure or adiposity measures.1 Diet and physical activity interventions were associated with lower systolic blood pressure (-0.8 mm Hg [95% CI, -1.30 to -0.31]), diastolic blood pressure (-0.42 mm Hg [95% CI, -080 to -0.04]), LDL cholesterol level (-2.20 mg/dL [95% CI, -3.80 to -0.60]), and adiposity-related outcomes such as weight (-1.07 kg [95% CI, -1.62 to -0.52]), BMI (-0.32 kg/m2 [95% CI, -0.51 to -0.13]), and waist circumference (-0.81 cm [95% CI, -1.32 to -0.30]).1 Generally, high-intensity interventions (>360 minutes) were most associated with changes in intermediate outcomes, specifically lower LDL cholesterol and adiposity measures.1

Observational evidence from large prospective studies and individual participant data meta-analysis of prospective cohort studies demonstrates that small changes in intermediate outcomes (i.e., lower blood pressure) were associated with small reductions in risk of cardiovascular-related mortality and all-cause mortality.1

The USPSTF found little direct evidence on the effectiveness of behavioral counseling interventions on all-cause mortality, CVD-related mortality, CVD events (such as myocardial infarction or stroke), or quality of life.1 In studies, CVD-related fatal and nonfatal events were rare, limiting robust analysis, with few group differences.1 A variety of self-reported quality of life measures were reported in 15 trials; group differences were generally very small and of unclear clinical significance.1

Harms of Counseling to Change Behavior

Of the 113 trials reviewed by the USPSTF, only 23 specifically reported on harms or lack of harms of behavioral counseling interventions.1 Overall, harms were rare and without statistically significant differences reported between intervention participants and control groups on any adverse events, serious adverse events, musculoskeletal injuries, or falls.1

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The USPSTF identified several gaps in the evidence where more research is needed.

  • Studies should enroll enough participants from populations disproportionately affected by CVD to understand the benefit of physical activity and dietary behavioral counseling interventions in these populations. Culturally appropriate and tailored intervention research may help reduce disparities related to cardiovascular health.
  • Future research should elucidate best practices for clinicians and patients to navigate known environmental and structural barriers to healthy diet and physical activity.
  • Future research should ensure that patient-reported quality of life outcomes related to cardiovascular health are consistently measured and reported.
  • Future research should validate and standardize dietary intake and physical activity instruments in collection and reporting.
  • Future research should design and test interventions to reduce sedentary behavior. The recent increase in working from home during the COVID-19 pandemic may present an opportunity to perform research on effective interventions that reduce sedentary time.
  • Future research that is adequately powered and of sufficient followup duration is needed in patients without known CVD risk.
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The American College of Cardiology and the American Heart Association (AHA) guidelines to prevent CVD emphasize a team-based approach, with consideration of the social determinants of health that affect patients to guide clinical decisions. The guidelines recommend healthy diet consumption along with 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity physical activity.28

The American College of Sports Medicine and the AHA recommend clinicians provide behavioral counseling on physical activity to all adults regardless of chronic conditions or risk factors. In 2018, they co-launched the “Exercise is Medicine” initiative, calling for clinicians to assess and promote physical activity of all patients.29

The American Academy of Family Physicians supports the 2017 USPSTF recommendation on this topic.30

The AHA recommends physical activity assessment and promotion in healthcare settings for all adult patients to prevent CVD.31

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1. Patnode CD, Redmond N, Iacocca MO, Henninger M. Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Review No. 217. AHRQ Publication No. 22-05289-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2022.
2. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-e596.
3. Centers for Disease Control and Prevention. Leading Causes of Death. Accessed December 15, 2021. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.
4. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.
5. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th edition. Accessed December 15, 2021. https://health.gov/dietaryguidelines/2015/guidelines/
6. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd edition. Accessed December 15, 2021. https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf.
7. Storey M, Anderson P. Income and race/ethnicity influence dietary fiber intake and vegetable consumption. Nutr Res. 2014;34(10):844-850.
8. Armstrong S, Wong CA, Perrin E, Page S, Sibley L, Skinner A. Association of physical activity with income, race/ethnicity, and sex among adolescents and young adults in the United States: findings from the National Health and Nutrition Examination Survey, 2007-2016. JAMA Pediatr. 2018;172(8):732-740.
9. Chai W, Fan JX, Wen M. Association of individual and neighborhood factors with home food availability: evidence from the National Health and Nutrition Examination Survey. J Acad Nutr Diet. 2018;118(5):815-823.
10. Scholes S, Bann D. Education-related disparities in reported physical activity during leisure-time, active transportation, and work among US adults: repeated cross-sectional analysis from the National Health and Nutrition Examination Surveys, 2007 to 2016. BMC Public Health. 2018;18(1):926.
11. US Preventive Services Task Force. Actions to transform US Preventive Services Task Force methods to mitigate systemic racism in clinical preventive services. JAMA. 2021 Nov 8.
12. Davidson KW, Krist AH, Tseng CW, et al. Incorporation of social risk in US Preventive Services Task Force recommendations and identification of key challenges for primary care. JAMA. 2021;326(14):1410-1415
13. U.S. Preventive Services Task Force. Procedure Manual. Accessed December 15, 2021. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual.
14. US Preventive Services Task Force; Curry SJ, Krist AH, Owens DK, et al. Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(11):1163-1171.
15. US Preventive Services Task Force. Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2020;324(20):2069-2075.
16. National Institute for Health and Care Excellence. Physical Activity: Brief Advice for Adults in Primary Care. Public health guideline [PH44]. Accessed December 15, 2021. https://www.nice.org.uk/guidance/ph44.mittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38-e360.
17. Lee-Kwan SH, Moore LV, Blanck HM, Harris DM, Galuska D. Disparities in state-specific adult fruit and vegetable consumption - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(45):1241-1247.
18. U.S. Community Preventive Services Task Force. Nutrition. Accessed December 15, 2021. https://www.thecommunityguide.org/topic/nutrition.
19. U.S. Community Preventive Services Task Force. CPSTF Findings for Physical Activity. Accessed December 15, 2021. https://www.thecommunityguide.org/content/task-force-findings-physical-activity.
20. U.S. Department of Health and Human Services. Move Your Way Community Resources. Accessed December 15, 2021. https://health.gov/our-work/nutrition-physical-activity/move-your-way-community-resources.
21. Centers for Disease Control and Prevention. State Health Equity Toolkit. Accessed December 15, 2021. https://www.cdc.gov/nccdphp/dnpao/health-equity/state-health-equity-toolkit/index.html.
22. US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325(16):1650-1656.
23. US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.
24. U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(12):836-845.
25. US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(19):1997-2007.
26. US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA. 2021;326(8):736-743.
27. US Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2017;318(2):167-174.
28. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646.
29. American College of Sports Medicine. Exercise is Medicine: A Global Health Initiative. Accessed December 15, 2021. https://www.exerciseismedicine.org/.
30. American Academy of Family Physicians. Healthful Diet and Physical Activity to Prevent Cardiovascular Disease (CVD). Accessed December 15, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/diet-cvd.html.
31. Lobelo F, Young DR, Sallis R, et al. Routine assessment and promotion of physical activity in healthcare settings: a scientific statement from the American Heart Association. Circulation. 2018;137(18):e495-e522.

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Rationale Adults Without Known CVD Risk Factors*
Benefits of counseling interventions to promote a healthy diet and physical activity
  • There is inadequate direct evidence that counseling interventions improve CVD and related health outcomes. Data directly assessing the effect of counseling interventions on CVD-related events and mortality were limited.
  • There is adequate evidence that counseling interventions provide a small benefit in improving intermediate outcomes associated with CVD such as blood pressure, LDL cholesterol, and body weight/adiposity.
  • There is adequate evidence that counseling interventions provide a small benefit in improving physical activity levels and dietary outcomes.
Harms of counseling interventions to promote a healthy diet and physical activity There is adequate evidence to determine the harms of counseling interventions. Based on the nature of the interventions, these harms can be bound as no greater than small in magnitude.
USPSTF Assessment The USPSTF concludes with moderate certainty that counseling interventions to promote a healthy diet and physical activity in adults without CVD risk factors has a small net benefit. Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling.

* Hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose/glucose tolerance, or mixed risk factors (e.g., metabolic syndrome or 10-year CVD risk ≥7.5%).

Abbreviations: CVD=cardiovascular disease; LDL=low-density lipoprotein; USPSTF=U.S. Preventive Services Task Force.

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