Nancy T. Artinian|Gerald F. Fletcher|Dariush Mozaffarian|Penny M. Kris?Etherton|Linda Van Horn|Alice H. Lichtenstein|Shiriki Kumanyika|William E. Kraus|Jerome L. Fleg|Nancy S. Redeker|Janet C. Meininger|Joanne Banks|Eileen M. Stuart?Shor|Barbara J. Fletcher|Todd D. Miller|Suzanne Hughes|Lynne T. Braun|Laurie A. Kopin|Kathy Berra|Laura L. Hayman|Linda J. Ewing|Philip A. Ades|J. Larry Durstine|Nancy Houston-Miller|Lora E. Burke
Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults
General Department of Preventive Medicine|Williams & Associates|Williams & Associates
homecirculationvol 122 4interventions promote physical activity dietary lifestyle changes cardiovascular risk factor reduction adults free accessreview articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessreview articlepdfepubinterventions promote physical activity dietary lifestyle changes cardiovascular risk factor reduction adultsa scientific statement american heart association nancy artinian gerald f fletcher dariush mozaffarian penny krisetherton linda van horn alice h lichtenstein shiriki kumanyika william e kraus jerome l fleg nancy redeker janet c meininger joanne banks eileen stuartshor barbara j fletcher todd miller suzanne hughes lynne braun laurie kopin kathy berra laura l hayman linda j ewing philip ades j larry durstine nancy houstonmiller lora e burke nancy artiniannancy artinian search papers author gerald f fletchergerald f fletcher search papers author dariush mozaffariandariush mozaffarian search papers author penny krisethertonpenny krisetherton search papers author linda van hornlinda van horn search papers author alice h lichtensteinalice h lichtenstein search papers author shiriki kumanyikashiriki kumanyika search papers author william e krauswilliam e kraus search papers author jerome l flegjerome l fleg search papers author nancy redekernancy redeker search papers author janet c meiningerjanet c meininger search papers author joanne banksjoanne banks search papers author eileen stuartshoreileen stuartshor search papers author barbara j fletcherbarbara j fletcher search papers author todd millertodd miller search papers author suzanne hughessuzanne hughes search papers author lynne braunlynne braun search papers author laurie kopinlaurie kopin search papers author kathy berrakathy berra search papers author laura l haymanlaura l hayman search papers author linda j ewinglinda j ewing search papers author philip adesphilip ades search papers author j larry durstinej larry durstine search papers author nancy houstonmillernancy houstonmiller search papers author lora e burkelora e burke search papers author search papers author behalf american heart association prevention committee council cardiovascular nursing originally published12 jul 2010httpsdoiorg101161cir0b013e3181e8edf1circulation 2010122406441other versions articleyou viewing recent version article previous versions july 12 2010 previous version 1 approximately 79 400 000 american adults 1 3 cardiovascular disease cvd1 cvd accounts 363 1 every 28 deaths united states leading cause death among men women united states killing average 1 american every 37 seconds1 older adults ethnic minority populations socioeconomically disadvantaged individuals increased prevalence cvd vascularmetabolic risk factors hypertension dyslipidemia diabetes likely 2 risk factors increased risk sedentary overweight obese unhealthy dietary habits210 black hispanic immigrants initially lower risk vascularmetabolic risk factors cvd usborn black hispanic individuals2 adapt diet activity habits country prevalence vascularmetabolic risk factors increases3 issues emphasizes importance interventions promote physical activity pa healthy diets american adultseven modest sustained lifestyle changes substantially reduce cvd morbidity mortality many beneficial effects lifestyle changes accrue time longterm adherence maximizes individual population benefits interventions targeting dietary patterns weight reduction new pa habits often result impressive rates initial behavior changes frequently translated longterm behavioral maintenance4 adoption maintenance new cardiovascular riskreducing behaviors pose challenges many individuals according national center health statistics life expectancy could increase almost 7 years forms major cvd eliminated5 improvements morbidity quality life would also substantial order achieve goals healthcare providers must focus reducing cvd risk factors overweight obesity poor dietary habits physical inactivity helping individuals begin maintain dietary pa changes year 44 billion including 33 billion medical costs 9 billion lost productivity due heart disease cancer stroke diabetes attributable poor nutrition6 year 2000 annual estimated direct medical cost physical inactivity 766 billion1there considerable published data strongly support benefits pa dietary changes means decrease morbidity mortality cvd stroke adults data presented discussed detail statements american heart association aha7 sources notable statements studies include limited statement exercise aha8 statement pa intervention studies aha9 statement diet lifestyle recommendations aha10 2005 dietary guidelines americans11 recommendation pa public health12 despite abundance data supporting benefits lifestyle changes cvd striking americans increasingly challenged growing burdens excess body weight limited pa suboptimal dietary habits lifestyle problems also associated many chronic diseases cvd stroke including type 2 diabetes osteoporosis depression many cancerscardiovascular risk factors combated controlled adherence current lifestyle recommendations one important example success achieved improving lifestyle habits achieved decline prevalent tobacco use 424 205 american adults 1965 200713 although work remains regard success tobacco cessation efforts provides strong basis optimism concerted evidencebased program education policy change individual interventions could successfully improve dietary pa habits united statesthe purpose scientific statement provide evidencebased recommendations implementing pa dietary interventions among adult individuals including adults racialethnic minority andor socioeconomically disadvantaged populations efficacious effective strategies summarized guidelines provided translate strategies practice individual provider environmental factors may influence design interventions well implications policy future research also briefly addresseddescription data search strategies evidence rating systemto identify articles concerned diet pa behavior change interventions individuals literature searches performed 5 databases medline cinahl cardiosource clinical trials cochrane library psycinfo included studies limited adult humans defined 18 years age english language randomized controlled quasiexperimental designs metaanalyses focused effects diet pa interventions weight blood pressure bp pa level aerobic resistance exercise fitness consumption calories fruits vegetables fiber total fat saturated fat cholesterol salt published january 1997 may 2007 landmark studies predate 1997 publication included review despite extensive search efforts relevant studies may identified overall studies representative capture state fieldunpublished reports reports published abstract form included considerable variation direction strength findings within studies reviewed however effect bias publication studies null results cannot ruled studies restricted conducted united states societal cultural factors affect feasibility success particular intervention strategies nonetheless findings may generalizable developed nations feeding trials observational studies specific nutrients observational studies aerobic capacity excluded given varying goals outcomes different identified intervention studies possible used common measure effect size es quantify compare success intervention14 recommendations follow aha american college cardiology methods classifying evidence table 1 table 1 definition classes levels evidence used dietary physical activity lifestyle changes recommendations226class iconditions evidence andor general agreement procedure treatment useful effectiveclass iiconditions conflicting evidence andor divergence opinion usefulnessefficacy procedure treatment class iiaweight evidence opinion favor procedure treatment class iibusefulnessefficacy less well established evidence opinionclass iiiconditions evidence andor general agreement procedure treatment usefuleffective cases may harmfullevel evidence adata derived multiple randomized clinical trialslevel evidence bdata derived single randomized trial nonrandomized studieslevel evidence cexpert opinion case studiesfindingsdetails studies behavioral change interventions related pa dietary outcomes presented tables 2 3 cognitivebehavioral strategies promoting change integrated across reports studies tables 2 3 organized according format intervention delivery majority studies assessed changes body weight andor specific eating patterns fruitsvegetables dietary fat except studies using standard behavioral interventions weight loss daily calorie fat gram goals provided studies target total energy intake shown tables 2 3 es betweengroup differences majority studies small ranging 000 033 except preliminary study carels et al15 used motivational interviewing augment behavioral intervention reported es 084 table 2 rcts interventions promote pa dietary lifestyle change nonminority samplesreferences year study designduration npopulationsampleinterventionoutcomescaloriesfatfruits vegetablesfibersodiumpaweightbpcholesterolglucosehemoglobin a1cprintonly delivery strategies hunt et al118 2004 2group rct12 mo n5473primary care practice subjects mildly controlled htn 58 women mean age 69 90 white retention 52i 2 educational packets sent 3 mo apart first focused htn lifestyle second medication adherence home bp monitoring bp log included letter pcpbp c 13777 vs 13577 p0229subjects groups randomly selected bp measured complete survey intervention group scored higher htn knowledge quiz 74816 vs 70616 p0019c subjects received usual care marcus et al79 1998 2group rct6 mo n19476 female mean age 443 938 white 82 employed mean 125 min moderate level pa baselinec 4 selfhelp booklets promoting pa mailed subjectspa group mean 976 min pawk compared group 1514 minwk significantly greater number subjects reached recommended pa c groupi computergenerated individually tailored reports selfhelp manuals matched stage motivational readiness reports consisted feedback 1 stage readiness pa 2 level selfefficacy decisional balance use cognitivebehavioral processes 3 comparative feedback 4 progress since last assessment motivationally matched manuals accompanied reports sent mailgroupbased intervention delivery strategies aldana et al113 2006 2group rct6 mo n34870 women mean age 50 93 white bmi 3133 retention intervention 88 control 95i 40lecture course 4 wks focus nutrition pa textbook workbook followed curriculum topics provided included assignmentsweight loss c 05 vs 45 kg p00001sbpdbp mm hg 555 vs 438 p00001cholesterol 6 vs 11 p0004 glucose 3 vs 1 p0005only withingroup changes reported p values significantc described andersen et al56 1999 2group rct1 n40women mean age 43 bmi 329 retention 98 16 wks 825 68 wksstructured aerobic exercise saelowfat diet weekly aerobic exercise classes 16 wksweight loss sae group 83 kg vs 79 kg 16 wks p008 es057 1 year sae regained 16 vs 008 kgsbp cholesterol improvement within groups p0001 16 wks nsd groupsmoderate lifestyle activitylowfat diet weekly group sessions focused moderate pa kept daily records wore pedometers received graphs pa feedback burke et al24 2006 4group rct18 mo n18287 women mean age 44 297 minority bmi 34 retention 86standard behavioral weight loss treatment sbt delivered 4 groups 1 sbtlactoovoveg lov dietnot preferred 2 sbtlov dietpreferred 3 sbtstandard weight loss dietnot preferred 4 sbtstandard weight loss dietpreferredweight loss diet groups 7075 kg nsd diet preference group es003ldl sbt 005 vs sbtlov 016 p0013sbt includes goal setting selfmonitoring feedback intervention 12 mo study gives 6mo report carels et al23 2004 2group rct1 n44100 women mean age 547 race reported 445 college degree 333 income 30 000 mean bmi 364lifestyle change lc 24 group sessions change weight pa 5 components lifestyle exercise attitudes relationships nutrition focused selfmonitoring controlling stimuli pa nutrition education modifying selfdefeating thoughts negative emotions setting realistic goals relationships relapse prevention weight maintenancecalories average daily caloric intake decreased 472 cal groups p005 percent energy fat saturated fat decreased 54 27 respectively p005 nsd groupspa fitness groups increased maximal oxygen consumption treadmill time weekly leisure time activity p005 nsd groupsweight loss mean weight loss groups 62 kg p005 nsd groupsbp groups mean decrease sbp 8 mm hg dbp 79 mm hg p005 nsd groups chol groups ldl decreased average 106 mgdl nsd groupslifestyle changeselfcontrol skills training lifestyle change plus combination didactic instruction individual activities weekly outofclass assignments strengthen selfcontrolcontinuedtable 2 continuedreferences year study designduration npopulationsampleinterventionoutcomescaloriesfatfruits vegetablesfibersodiumpaweightbpcholesterolglucosehemoglobin a1c heshka et al123124 2003 2group multicenter rct2 n42380 women age 4445 bmi 34selfhelp program sh two 20min counseling sessions nutritionist provision selfhelp resourcesweight loss sh group 13 vs commercial group 43 kg p0001 12 mo 02 vs 29 kg 2 p0001 es016commercial weight loss program food activity plans cognitive restructuring behavior modification plan weekly meetings 104 wks jakicic et al109 1999 3group rct18 mo n148women mean age 37 bmi 328 retention 78behavioral weight control program combined 1 longbout exercise lb 2 multiple shortbout exercise sb 3 multiple shortbout exercise home exercise equipment sbeq provided treadmillvo2 significantly increased compared baseline nsd among groupsweight loss sbeq 74 kg vs sb 37 p005 nsd lb group 58 es16 jeffery et al25 1998 5group rct18 mo n19380 female age 40 80 white bmi 31 retention 781 standard behavioral therapy weight loss sbt 2 sbtsupervised walks sw 3wk 3 sbtswpersonal trainer pt worked 23 subjects walks 4 sbtswmonetary incentives paid 15 walks 5 sbtswptin received abovepa subjects groups achieved study goal 1000 kcalwkweight loss kg sbt 76 vs sbtsw 38 vs sbtswpt 29 vs sbtswi 45 vs sbtswpti 51 kg treatment groups difference baseline 18 mo significant p003 sbt group greater lossessbtweekly group sessions 24 monthly thereafter 1 daily caloriefat goals pa 2501000 kcalwk writing group premier collaborative research group26 2003 3group rct6 mo n810adults stage 1 hypertension optimal bp 34 black 62 women mean age 50 years approximately 10 30 000 annual incomesubjects goals est estdash weight loss 15 lb subjects bmi 25 180 minuteswk moderate intensity pa daily intake 100 meq na daily intake 1 oz alcohol men oz womenfv servingsd change baseline 05 05 est 30 estdash est vs p079 comparisons p0001 total fat kcal 10 39 est 95 estdash comparisons p0001pa kcalkgd nsdweight loss change baseline 11 kg 49 kg est 58 kg estdash est vs estdash vs p0001 est vs estdash p007prevalence high bp 6 mo 26 group 17 est group 12 estdash group difference est p001 estdash p0001 est estdash p012established est 18 facetoface contacts 14 group meetings 4 individual sessions diaries used record pa calories naestablished plus dash estdash subjects received est plus instruction counseling dash diet dietary goals fv lowfat dairy saturated fat total fat diaries used record pa calorie na fv dairy fatadvice dietitian provided 30min individual session nonpharmacological factors affect bp provided printed educational materials counseling behavior change provided 4 individual counseling sessions lifestyle changedash diet included 912 servings fv per day lowfat dairy 23 servingsd 7 energy saturated fat 25 energy total fat mcmanus et al27 2001 2group rct18 mo n10190 female mean age 44 88 white bmi 34 retention 20 vs 54 18 molowfat lf diet 20 kcaltotal fat kcal lf 30 vs mf 35 p003weight loss lf 29 vs mf 48 kg 18 mo p0001 es033moderate fat mf 35 kcal mediterranean dietboth groups weekly group educational classes address behavioral modification skills pa selfmonitored weekly diaries feedback provided simkinsilverman et al66 2003 2group rct45 n535women peri postmenopausal predominantly white 355 overweight 11 obese retention 5 95c health education pamphlet assessment 6 18 30 42 54 mokcal c 248 vs li 1596 kcal p001 es011energy expenditure c 1133 vs 2749 kcal p0001 es014weight loss 55 li group baseline weight compared 26 c group p0001 mean weight change li group 01 kg baseline compared mean weight gain 24 kg c grouplifestyle intervention li phase 1 15 group meetings20 wks lifestyle changes modest weight loss pa phase 2 6 group meetings mo 654 mail telephone fu individual nutrition consultation offered lower ldl cholesterolcontinuedtable 2 continuedreferences year study designduration npopulationsampleinterventionoutcomescaloriesfatfruits vegetablesfibersodiumpaweightbpcholesterolglucosehemoglobin a1c toobert et al67 2005 2group rct6 mo n279postmenopausal women type 2 dm 90 white bmi 35 retention 88uc ongoing diabetes care mdtotal fat g uc 1621 vs mlp 466 g p0001 es20 fruit servingsd uc 16 vs 22 p0001 vegetable servingsd uc 20 vs 26 p0001pa metsdurationdays 559 uc vs 809 mlp p0009weight uc 934 vs mlp 917 kg p0004mediterranean lifestyle program mlp lifestyle change aimed behavioral risk factors affecting chd 25d retreat followed weekly 4h meetings 6 mo focus diet pa stress management social support wadden et al72 1998 4group rct1 n99women mean age 42 bmi 36 retention 602cognitivebehavioral treatment weight loss delivered 28 weekly sessions followed 10 biweekly sessions combined caloricrestricted diet plus 1 4 exercise groups 1 aerobic exercise 2 strength trainingaerobic 3 strength training 4 exercise beyond lifestyleactivityweight loss 4 groups 106114 kg nsd 1 3555 weight regained nsd wadden et al28 2005 4group rct1 n224men women mean age 436 65 white bmi 378all subjects diet 12001500 kcald exercise 30 mind days weekweight loss ct 12198 kg vs siba 5074 kg vs lma 6779 kg vs sibbt 7580 kg p0001 subjects ct group selfmonitored frequently weight loss 18198 kg vs 7775 kg p004sibutramine alone sib 8 brief visits pcp 1 3 6 10 18 40 52 wks received dose sibutramine wk 1 received print materials fitnesslifestyle modification alone lma wkly group meetings wks 119 every 2 wks wks 2040 followup visit wk 52 daily selfmonitoring food intake pa reviewed wkly meetingscombined therapy ct 2 treatments groups sibutramine plus brief therapy sibbt sibutramine group 1 met pcp 1015 min schedule group meetings wing et al29 1999 4group rct10 mo n166women men age 42 90 white bmi 312 retention 75951 recruited alone standard behavioral therapy weight loss sbt 2 recruited alone sbtsocial support 3 recruited friends sbt 4 recruited friends sbtsocial support sbt includes group sessions selfmonitoring calories fat pa weekly diaries feedback social support included intragroup activities intergroup competition groups 2 4weight loss recruited friends 77 kg recruited alone 43 kg p0001 es026 yeh et al68 2003 2group rct2 n80women age 3060 bmi 363 379 retention 33 sbi 35 cbofficebased counseling dietitian obc 6 intervention sessions 6 mooffer 6 moresaturated fat g obc 008 vs sbi 42 g 24 mo p007weight loss obc 40 vs sbi 17 6 mo p005 11 vs 06 24 mo nsskills based intervention sbi two 90min didactic sessions related diet behavior additional sessions technical skill building supermarket restaurants telephone email access dietitian rest 12 mocontinuedtable 2 continuedreferences year study designduration npopulationsampleinterventionoutcomescaloriesfatfruits vegetablesfibersodiumpaweightbpcholesterolglucosehemoglobin a1cindividualbased intervention delivery strategies ammerman et al98 2003 2group cluster randomized trial 8 rural health departments12 mo n46871 female mean age 55 80 white 75 hs educationsubjects groups informed cholesterol results letter lipids high informed needed treatmentdietary risk assessment score 21 units better si vs mi p0005nsd weight lossreduction total cholesterol similar groups 184 mgdl si vs 156 mgdl mi p006special intervention si 1 public health nurse directed component using food health program 3 counseling visits 2 referral local nutritionist lipids remained elevated 3 mo fu 3 reinforcement program 2nd half intervention1 telephone call nurse 2 newsletters structured individually tailored dietary counseling nurse facilitated dietary risk assessment illustrated goal sheets southern style cookbookminimal intervention mi initial letter cholesterol results intervention activities described burke et al30 2005 2group rct14 wks n6560 male 94 white bmi 3845 retention 98uc usual clinical carefat change score uc 23 vs 104 g p0035 es029 saturated fat change score uc 018 vs 23 g p0045 es028ldlc change score uc 025 vs 042 mgdl p0013 es030i telephonedelivered selfefficacybased counseling improve adherence cholesterollowering diet 6 sessions 12 wks included goal setting selfmonitoring feedback selfefficacy enhancement delichatsios et al130 2001 2group cluster randomized trial3 mo n50470 female 91 white mean age 54 yc usual pcp practicefv change fv intake group 06 ci 0308 servingsd higher control groupi 3 componentspersonalized diet recommendations stagematched dietrelated educational booklets mail provider endorsement recommendations 2 motivational interview counseling sessions telephone counseling encouraged goalsetting stage change messages elliot et al71 2007 3group cluster randomized trial12 mo n59997 male firefighters mean age 41 91 white income 50 000both intervention groups received health fitness guidefv team mi increased fv intake p005pa team mi increased situps 1 min p005weight team mi gained weight less gain uc p005team centered work groups designated leader met 11 45min sessions followed scripted lesson plans nutrition pa energy balance stress sleep dietary supplements members received baseline pa dietary lab assessment results followed goal settingmotivational interviewing mi participants randomly assigned 1 6 mi counselors 4 meetings mi counselor possibility 5 hours additional person telephone contactcontrol received test results explanation normal values free use initiative alter lifestylecontinuedtable 2 continuedreferences year study designduration npopulationsampleinterventionoutcomescaloriesfatfruits vegetablesfibersodiumpaweightbpcholesterolglucosehemoglobin a1c keyserling et al227 2group rct randomization clinicianpatient groups1 n37242 physicians 66 patient participants high cholesterol female 40 black 11 native american mean age 559 106 mean educationi 3 components1 cliniciandirected dietary component 2 referral local dietitian ldlc remained elevated 4 mo followup 2 risk factors chd 3 prompt clinician consider drug treatment based ldlc 7 mo followuptotal cholesterol 4mo followup total cholesterol decreased 033 mmoll group vs 021 mmoll c group 90 ci 002024 mmoll mean reduction 1y followup 009 greater group 90 ci 001019 mmoll changes ldlc similaruc physicians advised manage subjects hypercholesterolemia according usual practices marcus et al69 2007 3group rct12 mo n23982 female 903 white mean age 445 mean bmi 285 60 household income 50 000c health education material mailed schedule print telephone subjects completed pa log monthpa 6 mo subjects group 1233976 p group 12951565 reported larger increase min pawk subjects c group m77710189 p002 12 mo p group reported greater moderateintensity pa compared c group nsd p groupstelephone subjects received pa intervention materials telephone contact health educator educator incorporated individually tailored feedback generated expert computer system provided counseling using motivation stagedmatched manual