Implications for practice and research

• Clinicians need to engage community-based public health and other partners to deliver the intensity of diet and physical activity needed to have a positive impact on cardiovascular disease (CVD) risk.

• More research is needed to identify the most efficient (cost and time) means of intervention delivery to achieve positive short-term and long-term impacts.

Context

A substantial body of convincing evidence suggests that a healthy diet and physical activity are associated with reduction in cardiovascular events and mortality rates along with a number of other important health outcomes. However, many US adults are not meeting the recommendations.

This systematic review was conducted to address the following four topics: (1) the effect of dietary and physical activity counselling on patient health outcomes; (2) intermediate CVD-related outcomes; (3) behavioural outcomes; and (4) harms of counselling.

Findings

On the basis of the 74 trials reviewed, intensive combined lifestyle counselling in people with CVD risk factors improved dietary and physical activity behaviours and reduced cholesterol levels, blood pressure, weight, glucose levels and incidence of diabetes at 12–24 months. The average effect of these reductions was modest, but observational studies suggest this can be associated with reductions in CVD events.1 ,2 The magnitude of effect is consistent with changes seen in other reviews of behavioural counselling on diet and exercise.3 The review found more limited information about long-term benefits.

Commentary

Primary care clinicians face many challenges in deciding the focus for health counselling with the limited time they have available with patients. It is important to use evidence-based methods to determine how that time can be used effectively for maximum health impact. Lin and colleagues used rigorous methodology for article selection, review, synthesis and analysis. The review was hampered somewhat by limited reporting in the published literature on patient health outcomes, long-term follow-up of outcomes, and any harm associated with dietary and physical activity counselling.

The findings of this systematic review support continued efforts to integrate lifestyle (diet and physical activity) counselling into primary care patient counselling, however, the level of intervention intensity needed to have a significant impact may be more than what can be feasibly implemented in a primary care setting. The review found a wide range of intensity for effective interventions ranging from 2 h to more than 30 h of contact time. Future research is needed to evaluate minimum intensity, frequency, or duration of contacts required to maintain effectiveness.

The potential need for intensive and/or long-term intervention to impact diet and physical activity raises the importance of a patient-centred medical homes approach, where clinicians refer patients at high risk for CVD to additional sources of care in their communities that can provide more intensive diet and physical activity interventions. This could include referral to a registered dietitian, as well as to community-based organisations that incorporate opportunities to enhance physical activity and/or dietary habits. It is important to consider the ability of the referred patients to pay for these services and seek options that are affordable or can be reimbursed through third-party payers.