Strengthening the Pillars of Prevention: A Practical Framework to Enhance Lifestyle Counseling

Lifestyle habits are the cornerstone of cardiovascular disease prevention. Numerous studies have demonstrated the association of healthy lifestyle habits including adequate physical activity, healthy diet, and abstinence of tobacco use with markedly lower rates of cardiovascular disease (CVD), increased longevity, and less development of co-morbid chronic medical conditions.^1-3 These habits also impact the development and control of traditional cardiovascular risk factors including high blood pressure, elevated cholesterol, and diabetes and healthy lifestyle across the life course is emphasized as the core component of risk factor management.⁴ These complementary components, lifestyle behaviors and risk factors, were codified into a framework of ideal cardiovascular health by the American Heart Association (AHA) in 2010, with the goal of preserving and improving cardiovascular health in the population.⁵ Unfortunately, pervasive ideal cardiovascular health remains an elusive goal, with less than 5% of the adult population meeting this metric.⁶ Poor rates of healthy lifestyle habits underpin this shortcoming, including less than 1% achieving healthy dietary patterns and less than half meeting physical activity recommendations.⁶

So why are healthy lifestyle habits so hard to achieve? There are multiple contributors including patient level factors such as misperceptions regarding the value of lifestyle interventions, conflicting messaging on optimal habits, and perceived challenges of achieving lifestyle goals. Structural elements comprising social determinants of health such as lack of access to safe exercise spaces and availability of healthy food items also contribute. Importantly, misaligned incentives, time constraints, and lack of training lack in lifestyle counseling result in poor rates of behavioral counseling in clinical practice, including nutrition and physical activity counseling that occurs in <20% of visits. This is despite strong evidence supporting the effectiveness of lifestyle counseling in clinic visits. For example, randomized trials of physical activity counseling in primary care have demonstrated the need to counsel only 12 sedentary individuals for one to achieve recommended physical activity levels.⁷ Further, nutrition and physical activity counseling for higher risk individuals has been shown to reduce CVD events and improve blood pressure, blood glucose, and lipid levels.⁸ Accordingly, the US Preventive Services Task Force (USPSTF) recommends providing behavioral counseling to promote healthy diet and physical activity for all adults 18 years and older at increased risk of CVD.⁹

Here, the companion AHA statements on Strategies for Promotion of a Healthy Lifestyle in Clinical Settings – Pillars of Ideal Cardiovascular Health and Special Considerations for Healthy Lifestyle Promotion Across the Lifespan in Clinical Settings are welcomed documents providing tangible and practical strategies to enhance lifestyle counseling in the clinical setting. The core construct of these documents is the 5 A’s model which was originally developed by the National Cancer Institute for smoking cessation counseling,¹⁰ but has since been adapted for many additional lifestyle interventions. The inherent appeal of the 5A’s model is the ability to apply a simple, structured approach for lifestyle counseling in busy clinical practice settings. It is rooted in behavior change theories that address factors specific to the individual as well as process items between the individual and external influences.¹¹ The core components- assess, advise, agree, assist, and arrange – can be applied to different lifestyle domains with slight variation.

In this first statement, the authors provide specific, detailed guidance on how to apply and adapt each of the 5 A’s for nutrition, physical activity, and tobacco use counseling, as well as to sleep and psychological well-being and the use of technology for behavior change. There are several tools to support the Assess step including diet assessment questionnaires and a simple two question screen known as the Exercise Vital Sign which can be embedded into the electronic health record to facilitate universal acquisition.¹² In general, physicians are more apt to apply the Assess and Advise steps and rarely engage in the Agree and Assist steps which entail shared decision making with specific goal setting in partnership with patients.^{13, 14} However, these latter two steps may be most motivating to patients in addressing their specific needs and perspectives on change. The authors endorse development of SMART (specific, measurable, achievable, realistic, and timed) goals with patients in the Agree step and anticipating barriers and troubleshooting these barriers in partnership with patients in the Assist step.

Interestingly, although not part of the 7 ideal cardiovascular health metrics, the authors include sleep behavior as one of the lifestyle objectives of counseling in this statement. Both sleep duration and sleep disordered breathing associate with CVD risk and development of CVD risk factors, and there is increasing focus on optimizing sleep habits as a strategy to improve CVD health,¹⁵ although there is a paucity of randomized intervention studies in this area. In addition, the authors emphasize consideration of psychological health or well-being in lifestyle counseling, acknowledging the link between psychological well-being and successful engagement in health behaviors.¹⁶ Further, there is also the reciprocal benefit of lifestyle behaviors such as increased exercise improving psychologic well-being.

It is becoming increasingly apparent that social determinants of health, defined as “the circumstances in which people are born, grow, live, work, and age, and the systems put in place to deal with illness”,¹⁷ have a dominant influence on cardiovascular health and health behaviors.¹⁸ The AHA/ACC 2019 Primary Prevention Guidelines instruct that social determinants of health should inform all preventive recommendations (Class I recommendation),¹⁹ and specific guidance on how to incorporate social determinants of health considerations into the 5 A’s framework was provide by the authors in the second statement regarding Special Considerations for Healthy Lifestyle Promotion Across the Lifespan in Clinical Settings.

A salient example is physical activity counseling. Here, the two question Exercise Vital Sign regarding frequency and duration of moderate intensity physical activity in the Assess step is incomplete without additional context such as access to facilities for physical activity and safety of such neighborhood resources. Agreeing on specific goals and anticipating barriers in the Assist step must incorporate discussion about feasibility informed by socioeconomic position, residential environment, and other factors. Indeed, without acknowledging social determinants of health, lifestyle counseling is likely to be infective. Similarly, contextualizing lifestyle counseling recommendations to specific phases along the life course including during pregnancy, childhood and adolescence, and for older age groups as outlined in the second statement recognizes and addresses unique aspects of each phase.

Despite the obvious appeal of applying a simple, efficient, time tested framework to enhance lifestyle counseling in clinical practice, several questions remain regarding expansion of the 5 A’s framework advocated in these statements. First, the optimal methods of teaching this framework or lifestyle competencies in general to practicing clinicians and in medical curricula is unclear.²⁰ Further, although these statements focus on individual patient-clinician encounters, adaptation to a team based care model where the 5 A components are distributed or reinforced among team members could be an effective strategy. Importantly, whether broader implementation of the 5 A model for lifestyle counseling will meaningfully impact population health is uncertain. The USPSTF recommends an intensive approach to behavioral counseling, encompassing a median of 12 contacts, with an estimated 6 hours of contact over 12 months.⁹

Nevertheless, adoption of lifestyle counseling and lifestyle interventions have lagged far behind application of pharmacologic treatments and other therapeutics in the prevention arena despite their proven effectiveness and fundamental role in preserving cardiovascular health. Strategies to strengthen and enhance these pillars of prevention are sorely needed. The recommendations provided in these AHA statements fill a critical void, empowering clinicians with practical methods for partnering with patients in effective lifestyle change.