We know how to lower our risk of heart disease, yet it remains the leading killer of Americans year after year. That’s because the most powerful ways to fend off heart attacks and strokes are also the hardest. Changing our diet and exercise habits involves changing our lifestyles, and doctors have yet to come up with the perfect prescription for that.
But a group of government-convened experts says that one strategy shows promise. They studied the latest trials investigating what works and what doesn’t in getting people to eat healthier and move more, and found that behavioral counseling, either by physicians or nurses or specially trained counselors, can lower risk of heart problems in people who are overweight or obese.
“Intensive behavioral counseling does seem to move the needle,” says Dr. Michael LeFevre, chair of the U. S. Preventive Services Task Force and vice chair of family and community medicine at the University of Missouri Columbia. “We can take people at elevated risk – for starters, people who are overweight or obese and have at least one other risk factor for heart disease -- and saw modifications in their risk factors that we think are great enough to have an impact on their health down the road.”
The task force reviewed 74 trials of intensive behavioral counseling – which included education about heart health, nutrition and physical activity, as well as individualized programs in which the participants were provided feedback and problem-solving strategies – and heart outcomes. The counseling was not associated with any harms or serious adverse events, but the sessions did lead to lower cholesterol levels and blood pressure over two years and a decrease rate of diabetes over four years. About a quarter of people were exercising at a moderate to intense level (150 minutes of exercise per week) after several years compared to 10% who were at the start of the studies.
That’s good news, says LeFevre, and prompted the task force to recommend behavioral counseling in a statement published in the Annals of Internal Medicine to help people reduce their risk of heart disease.
The advice is an endorsement of the more formal counseling that more primary care doctors are relying on help their at-risk heart patients. It’s also a definitive statement against the current standard in which doctors merely urge their patients to lose weight or exercise more. “What we didn’t find evidence to support is what most of us do in our practice,” says LeFevre, who is a practicing primary care doctor. “And that is, we just say to John Doe sitting across from us who is overweight, has high blood pressure and smokes, to lose weight. John says, ‘I’m working on that.’ And I say ‘Let me know if I can help – just cut back to eating 1500 calories a day and walk every day.’ We don’t find any evidence that helps.”
What does work, he says, is a program that links both diet and exercise interventions, and that typically helps participants over several sessions occurring over several months, and involves many hours of interaction with a counselor. In those sessions, setting goals and addressing barriers to reaching those goals is an important part of the behavioral counseling – that’s what helps the patients to actually change their behavior rather than simply think about it.
But as a primary care doctor, LeFevre admits that the counseling isn’t exactly practical or widespread – yet. “One of the major barriers for implementation is that the resources aren’t out there. Many physicians simply don’t have the personnel, programs or location to which to refer people to make this happen.”
That’s the purpose of the USPSTF recommendation—by providing the scientific evidence supporting the benefits and effectiveness of behavioral counseling, LeFevre and the task force members hope that more doctors and hospitals will provide such programs to help their patients—and potentially contribute to lowering heart attacks and heart disease deaths. “We know the risk factors for heart disease pretty well, and we know that behavior change can alter your risk. So the question is, what can the health care community do to support that behavior change? We combed through the literature and looked at all the studies, and this is what seems to work,” he says.