Chronic Disease Prevention Linked To Patient Engagement, Counseling


Patient engagement in the form of behavioral counseling sessions about healthy behavior change aided in chronic disease prevention, according to a new evidence report published in JAMA.

CVD is the leading cause of death in the country, killing over 650,000 Americans each year. The report shows that counseling to encourage a healthy diet and physical activity in populations with CVD risk factors such as high blood pressure, cholesterol, and lipid levels improves patient outcomes.

Observational evidence shows associations between lower levels of CVD risk factors and lower cardiovascular-related mortality rates, however little research had been done on how effective behavioral counseling is at reducing CVD events and mortality until now.

The report, which analyzed 94 randomized clinical trials (RCTs), found that patient engagement in behavioral counseling sessions resulted in a 20 percent lower risk of cardiovascular disease (CVD) events for at-risk adults.

The interventions involved an average of six contact hours and 12 sessions over the course of a year. The sessions varied in format and recommendations, but 95 percent addressed both physical activity and diet.

Both reviews showed that behavioral counseling in people at risk for CVD was associated with improvements in intermediate outcomes such as blood pressure, lipid levels, glucose levels, and adiposity as well as behavioral outcome improvements such as dietary intake and physical activity.

However, the finding that behavioral counseling interventions are associated with a lower risk of CVD events is new.

“A wide range of behavioral counseling approaches improved health profiles. Similar effect sizes were found for most outcomes, compared with the previous review,” the researchers noted. “This was observed despite the inclusion of weight loss studies in adults with relevant CVD risk factors and the exclusion of studies conducted predominantly in adults with prediabetes or diabetes.”

The largest study included in the literature review, Prevención con Dieta Mediterránea [PREDIMED], accounted for half of the participants. Patients who received behavioral counseling in this study had a 3.6 percent rate of CVD events, compared to the control group that had a 4.4 percent rate of CVD events.

However, the PREDIMED study did not produce consistent evidence that supported physical activity as a predictor for positive CVD health outcomes.

“The finding of no consistent evidence of benefit for physical activity outcomes is surprising and may reflect limitations in the evidence,” the researchers explained.

“The difference in results between continuous outcomes showing no benefit and dichotomous outcomes showing marked improvement suggests that physical activity reporting is not representative in this body of literature, which included few trials exclusively addressing physical activity,” they continued.

One to two years after the behavioral counseling interventions, the researchers saw statistically significant reductions in continuous measures of blood pressure, fasting glucose levels, low-density lipoprotein cholesterol levels, and adiposity.

This report, conducted in conjunction with a review addressing abnormal blood glucose levels, provides evidence on the positive effect behavioral counseling in adults with CVD risk factors has on chronic disease prevention.

However, the researchers noted that further understanding is needed regarding how weight loss in the context of behavioral interventions can affect risk factors of CVD.

“Robust analyses of the importance of weight loss on intermediate outcomes are best provided by individual patient–level data and direct within-study comparisons of interventions with and without weight loss goals, both of which are sparse,” according to the review.

Many interventions included weight loss goals for participants, but some within-study comparisons show that CVD risk reduction can occur in the absence of weight loss. Therefore, among overweight people, especially those who have a history of unhealthy or unsuccessful weight loss attempts, promoting diet and physical activity goals without targeting weight loss is likely to improve health.

“The Nurses’ Health Study and the Health Professionals Follow-up Study revealed that all-cause mortality was lower in people with BMIs of 30.0 to 39.9 who had engaged in at least 3 healthy behaviors (including healthy diet, physical activity, moderate alcohol consumption, and not smoking) than in people of healthy weight who reported only 1 of these behaviors,” the researchers noted.

These findings could be used to update the prior review that informed a 2014 US Preventive Services Task Force (USPSTF) recommendation for providers to offer behavioral counseling to patients at risk for CVD, the researchers concluded.