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 That includes overweight people with high blood pressure, high
cholesterol, ‘metabolic syndrome’ or blood sugar levels higher then
normal and on the cusp of type 2 diabetes.
A literature review commissioned for the government-backed USPSTF,
published in the Annals of Internal Medicine, found that intensive
behavioral counseling can help lower these patients’ risk for heart
problems.
“My message for patients would be that we have the ability by
changing our behavior to modify our risk for heart disease and
stroke and your doctors can help you do that,” Dr. Michael L.
LeFevre, the chair of the Task Force, told Reuters Health by phone.
LeFevre is also vice chair in the Department of Family and Community
Medicine at the University of Missouri School of Medicine in
Columbia.
The recommendations are targeted to health care providers more than
to patients, LeFevre said.
To patients, he says, “The most important thing that we can do right
now is have you lose some weight, be more active but just offering
that advice and giving you a pamphlet, we don’t really find any
evidence that that’s helpful.”
Instead, the Task Force review found, intensive behavioral
counseling - involving multiple sessions with experts in nutrition
and exercise over an extended period, for several months to a year -
can help people lose weight and bring down their blood pressure and
cholesterol.
The researchers reviewed 74 studies of various lifestyle
interventions and found that with intensive counseling, many health
markers were improved one and two years later, and the risk of
diabetes decreased.
“This crystallizes 25 years of research and a huge number of studies
but I don’t think this is new or earth shattering information,” said
Dr. Jennifer S. Lin of the Kaiser Permanente Center for Health
Research in Portland Oregon.
Lin was the lead author of the literature review.
There is a great deal of data on people with heart attack and stroke
risk factors and most of those studies focused on a combination of
diet and exercise counseling, so those kinds of programs have the
most evidence behind them at this point, she said.
“On average we’re talking about a few milligrams of cholesterol per
deciliter of blood or a couple of millimeters of Mercury decrease in
blood pressure,” Lin told Reuters Health by phone.
“We’re calling that a modest benefit applied to a population but
even these modest benefits translate into health outcomes that
patients can actually feel,” she said.
Patients can’t necessarily feel when their blood pressure goes down,
but they can feel if they do or do not have a heart attack, she
said.
The best counseling interventions are not only frequent but
conducted by trained dietitians, nutritionists, health educators and
physiologists, she said.
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“They’re more than just didactic, more than classroom based
interventions, they’re individualized,” she said.
One-on-one counseling gives experts time to assess the barriers to
healthy diet and exercise for each person and help them overcome
them, LeFevre said.
“We need to see people repeatedly, to work with them and reinforce
what’s going on,” LeFevre said.
The USPSTF issued the same recommendation for the first time in
2012, but only for obese patients without heart disease risk
factors.
While family physicians could provide these counseling services
themselves, most of the programs studied involved referrals to
experts in the same office or elsewhere in the community, he said.
“To be perfectly honest, a rate limiting step for implementation of
this guideline is that there are a lot of doctors out there but
(they) don’t really have the time or skills to do this themselves,
or the resources,” LeFevre said.
Even sending patients to other experts means finding those people
and coordinating care with nutrition and exercise programs and
checking in periodically to see how things are going, he said.
Right now, larger health organizations like Kaiser Permanente in
California or Group Health in Washington are most likely to be able
to do this, he said. For doctors outside large health systems, it is
much easier to order a blood test or write a prescription than
coordinate long-term behavioral counseling, he said.
“It’s problematic that this kind of care is generally not paid for
by the U.S health system,” Lin said. “Those resources should be made
more available.”
There are commercial diet and exercise programs which are legitimate
and good at what they do but the patient needs to pay out of pocket,
she said.
“Many primary care physicians and many patients would not have
access to these types of interventions,” she said.
SOURCE: http://bit.ly/1i46lF7
Annals of Internal Medicine, August 25, 2014.
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