Background
Methods
Results
CPG code | Year | Country | Developing Organization | Title |
---|---|---|---|---|
Global cardiovascular disease | ||||
CVD 1 [15] | 2012 | Australia | National Vascular Disease Prevention Alliance | Guidelines for the management of absolute cardiovascular disease risk |
CVD 2 [16] | 2014 | UK | National Institute for Health and Care Excellence | Prevention of cardiovascular disease (PH25) |
CVD 3 [17] | 2016 | EU | European Society of Cardiology | European Guidelines on cardiovascular disease prevention in clinical practice |
CVD 4 [18] | 2017 | UK | Scottish Intercollegiate Guidelines Network | Risk estimation and the prevention of cardiovascular disease |
CVD 5 [19] | 2019 | Netherlands | Dutch College of General Practitioners | Cardiovascular risk management (M84) |
CVD 6 [20] | 2018 | Australia | National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand | Guidelines for the prevention, detection, and management of heart failure in Australia |
CVD 7 [21] | 2019 | U.S | American College of Cardiology & American Heart Association Task Force on Clinical Practice Guidelines | Guideline on the primary prevention of cardiovascular disease |
Lifestyle behavior | ||||
LSt 1 [22] | 2012 | U.S | U.S. Preventive Services Task Force | Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors |
LSt 2 [23] | 2014 | U.S | American College of Cardiology Foundation & American Heart Association | Guideline on lifestyle management to reduce cardiovascular risk |
LSt 3 [24] | 2014 | UK | National Institute for Health and Care Excellence | Behavior change: individual approaches (PH49) |
Overweight & obesity | ||||
OW 1 [25] | 2012 | U.S | U.S. Preventive Services Task Force | Screening for and management of obesity in adults |
OW 2 [26] | 2013 | Australia | National Health and Medical Research Council | Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia |
OW 3 [27] | 2014 | U.S | American College of Cardiology Foundation & American Heart Association & The Obesity Society | Guideline for the management of overweight and obesity in adults |
OW 4 [28] | 2014 | U.S | Department of Defense & Department of Veterans Affairs& Veterans Health Administration | Clinical practice guideline for screening and management of overweight and obesity |
OW 5 [29] | 2014 | UK | National Institute for Health and Care Excellence | Obesity prevention (CG43) |
OW 6 [30] | 2015 | Canada | Canadian Task Force on Preventive Health Care | Recommendations for prevention of weight gain and use of behavioral and pharmacological interventions to manage overweight and obesity in adults in primary care |
OW 7 [31] | 2015 | UK | National Institute for Health and Care Excellence | Maintaining a healthy weight and preventing excess weight gain among adults and children |
Blood lipids & cholesterol | ||||
LCh 1 [32] | 2014 | UK | National Institute for Health and Care Excellence | Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease (cg181) |
LCh 2 [33] | 2014 | U.S | Department of Defense & Department of Veterans Affairs & Veterans Health Administration | Clinical practice guideline for the management of dyslipidemia for cardiovascular risk reduction |
LCh 3 [34] | 2018 | U.S | American College of Cardiology & American Heart Association Task Force on Clinical Practice Guidelines | Guideline on the management of blood cholesterol |
LCh 4 [35] | 2019 | EU | The Task Force for the management of dyslipidemias of the European Society of Cardiology and European Atherosclerosis Society | Guidelines for the management of dyslipidemias: lipid modification to reduce cardiovascular risk |
Hypertension | ||||
BP 1 [36] | 2014 | U.S | Department of Defense & Department of Veterans Affairs & Veterans Health Administration | Clinical practice guideline for the diagnosis and management of hypertension in the primary care setting |
BP 2 [37] | 2014 | U.S | Community Preventive Services Task Force | Team-based care to improve blood pressure control |
BP 3 [38] | 2020 | Canada | Hypertension Canada | Comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children |
Blood glucose & type 2 diabetes mellitus | ||||
DM 1 [39] | 2013 | Canada | Canadian Diabetes Association | Clinical practice guidelines for the prevention and management of diabetes in Canada: Introduction |
DM 2 [40] | 2014 | UK | National Institute for Health and Care Excellence | Type 2 diabetes prevention: population and community-level interventions (PH35) |
DM 3 [41] | 2019 | EU | European Society of Cardiology & European Association for the Study of Diabetes | Guidelines on diabetes, pre-diabetes, and cardiovascular diseases |
Focus of physical activity intervention | Target population | Recommendation | Details of recommendation | Guideline reference number (see Table 1 for details) |
---|---|---|---|---|
Global CVD prevention | General adult population, regardless of CVD risk factors | All adults should be advised to participate in: At least 30 min of moderate intensity (aerobic) PA on at least 5 days of the week (minimum of 150 min/week), or preferably every day of the week | PA: Any bodily movement produced by skeletal muscles that requires energy expenditure Cardiorespiratory fitness: ability of the body to use oxygen to do PA, improved by PA Aerobic PA: movements of large muscle mass in a rhythmic manner for a sustained period Moderate intensity: breathing faster than normal / 3.0–5.9 METS / Increase of breathing rate, heart rate, & warmth, possibly accompanied by sweating / Can be continued for many minutes without exhaustion feeling Prescription of 4 dimensions: Frequency, duration, intensity & type – Taking into account contraindications (individual's condition) Duration: No need for continuous PA to have benefit; longer sessions have no different effect on CHD risk compared with shorter sessions, as long as total energy expenditure is similar | CVD 1 CVD 2 CVD 3 CVD 4 CVD 5 CVD 6 CVD 7 LSt 2 LCh 2 LCh 3 LCh 4 BP 1 BP 3 DM 2 |
OR | ||||
At least 15 min of vigorous intensity (aerobic) PA on at least 5 days of the week (minimum of 75 min/week), or preferably every day of the week | CVD 3 CVD 7 LSt 2 | |||
OR | ||||
An equivalent combination thereof, performed in sessions with a duration of at least 10 min/session | CVD 3 CVD 4 CVD 7 OW 4 | |||
PA may include occupational and/or leisure-time activity and should incorporate accumulated bouts of moderate-intensity activities | Type of PA: Active living (non-recreational active travel, household work, gardening), occupational activity (at work), leisure time activity (non-occupational) & exercise (structured and done for specific reason, e.g. brisk walking, cycling, hiking, jogging, swimming) | CVD 4 CVD 5 OW 4 OW 7 | ||
All patients, irrespective of health, fitness or activity level, should be encouraged to increase activity levels gradually Those who are moderately active and are able to increase their activity should be encouraged to do so. Activity can be increased through combination of changes to intensity, duration or frequency For additional benefit in healthy adults, a gradual increase in aerobic PA to 300 min a week of moderate intensity, or 150 min a week of vigorous intensity aerobic PA, or an equivalent combination thereof is recommended | Inverse dose–response relationship between PA levels and CVD risk Potential risk of adverse events associated with vigorous—& high-intensity exercise are extremely low (no significant difference when compared to moderate-intensity PA) | CVD 3 CVD 4 CVD 5 OW 7 LSt 2 LCh 2 DM 3 | ||
Individuals should be advised to minimize the amount of time spent being sedentary (sitting) over extended periods; e.g. by reducing screen time and taking regular breaks from sitting both at home and at work | Provide general advice to minimize periods of prolonged sitting: - High levels of total sedentary behavior are associated with higher risk of CVD & mortality - High levels of sedentary behavior may be associated with additional CVD risk at any level of PA - Undertaking very high levels of PA (> 1 h/day moderate to vigorous PA) may eliminate the association between excess sitting & CVD risk | CVD 3 CVD 4 CVD 5 CVD 7 OW 7 | ||
Weight management | Adult population with overweight/ obesity | For adults who are overweight or obese, strongly recommend lifestyle change by participating for ≥ 6 months in comprehensive lifestyle interventions, including: reduced energy intake, increased PA and measures to support behavioral change (behavioral strategies) | Comprehensive lifestyle interventions: multicomponent interventions, with combination of 3 components nutrition, PA & behavior change (BCT). Less amount of activity is needed for weight loss (because of energy deficit from diet + PA together), BCT assists pat in adhering to intervention Prevent weight regain: Maintaining high levels of PA (approximately 60 min per day) combined with other behavioral strategies | CVD 7 LCh 4 OW 2 OW 3 OW 4 OW 7 BP 3 |
For adults who are overweight or obese, prescribe approximately 300 min of moderate intensity activity, or 150 min of vigorous activity, or an equivalent combination of moderate intensity and vigorous activities each week combined with reduced dietary intake, to result in weight loss and gradually increase PA levels to prevent weight regain after initial weight loss | CVD 3 OW 2 OW 4 | |||
Adult population with combined CVD risk factors | Counsel overweight and obese adults with CVD risk factors (high BP, hyperlipidemia, hyperglycemia) that lifestyle changes that produce even modest, sustained weight loss of 3–5% produce clinically meaningful health benefits, and greater weight loss produces greater benefits | Dose–response: between amount of weight loss & lowering of BP and improvements in lipid/glycaemia profiles | OW 3 | |
Blood glucose management | Adult population with hyperglycemia or T2DM | A structured program of lifestyle modification that includes moderate weight loss and regular PA should be implemented to reduce the risk of T2DM in individuals with impaired glucose tolerance (prediabetes, IGT) and impaired fasting glucose (IFG) and A1C 6.0–6.4% | Target population for primary prevention: 1. High-risk individuals (e.g. obesity, IGT); 2. High-risk sub-groups (e.g. low SES); 3. General population | CVD 7 DM 1 DM 2 DM 3 |
General adult population, adult population with hyperglycemia or T2DM | Advise adults to engage in resistance (muscle-strengthening) training on at least two days a week, such as carrying heavy load, heavy gardening, weight training, push-ups or sit-ups (e.g. 9 exercises, 3 sets & 11 repetitions, intensity 70% of 1-max repetition) | Resistance training: Muscle strengthening of all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) Limited evidence for resistance training, but no evidence to exclude it from exercise programs (may confer pat benefits as well) Hypertensive individuals (SBP/DBP of 140–159/90–99 mm Hg): resistance or weight training exercise does not adversely influence the blood pressure T2DM: Specifically for DM prevention, combination of both aerobic & resistance exercise is effective | CVD 3 CVD 4 CVD 5 LSt 2 LCh 1 BP 1 BP 3 DM 3 |
Field Subfield | Recommendation | Details of recommendation | |
---|---|---|---|
Support & follow-up Global CVD prevention—low to medium intensity | Patient be seen within one month of initiation of lifestyle therapy to determine adequacy of risk factor management, degree of patient adherence, presence of adverse effects | Tailor the support and follow-up: Intensity & frequency based on individual need Plan reviews: Before, during & after behavior change intervention to assess progress towards goals Very brief intervention: (10–15 min) Target general public & focus on motivation & information Brief intervention: (15–25 min) Target low SES people or people whose health/wellbeing could be at risk Extended brief intervention: (30 min or more) Target people with high risk behavior; health problems; comorbidities; increased risk of harm; increased need for support to reach/maintain change High intensity intervention: (over 30 min) Target people at high risk of causing harm to their health/wellbeing; who have not benefited lower-intensity interventions; who have medical condition that needs specialist advice/monitoring; overweight population who are aiming to lose weight | BP 1 |
Regular assessment and counselling on PA is recommended to promote the engagement and, if necessary, to support an increase in PA volume over time | CVD 3 CVD 7 | ||
Adults at higher absolute risk of CVD should be given more frequent and sustained lifestyle advice, support and follow-up to achieve behavioral change | CVD 1 | ||
Deliver very brief, brief, extended brief and high intensity behavior change interventions and programs | LSt 3 | ||
Ensure behavior change is maintained for at least a year | LSt 3 | ||
Once the patient's risk CVD factors are controlled, at least annually follow-up is suggested (more frequently as indicated), depending on patient preference | BP 1 | ||
Weight management- high intensity | For active weight management in adults, prescribe on-site, high-intensity interventions = ≥ 14 sessions in 6 months with fortnightly review for the first 3 months, and at least 12 contacts within 12 months). Assess adherence to the weight loss program by measuring the patient’s weight and providing feedback and ongoing support | Intensive: Multiple contacts over extended periods (5–26 contacts/9–12 months) - Short-term: At least weekly - Intermediate-term: At least weekly to monthly for another 6 months - Long-term: After the first year, at least bimonthly | CVD 7 OW 2 OW 3 OW 4 |
Advise overweight and obese patients who have lost weight to participate long term (≥ 1 year) in a comprehensive weight loss maintenance program consisting of all behavioral components and ongoing support, with additional intervention as required | Continued provision of comprehensive weight loss maintenance program, on-site or by telephone, for periods up to 2,5 years after initial weight loss | CVD 7 OW 3 OW 4 | |
Behavior change Timing | For adults who are overweight or obese, discuss readiness to change lifestyle behaviors | Awareness: Make people aware of their level of CVD risk in relation to lifestyle behavior Timing of the intervention: Conform to current stage of motivation since people are most susceptible for lifestyle change interventions when exposed at a time when they are most open to change (e.g. following profiling results revealing elevated CVD risk) | OW 2 |
Counseling content | Provide structured information and combined behavioral counseling regarding lifestyle behaviors (e.g. healthy diet & PA), in order to prevent CVD and to control CVD risk factors to patients with: 1. normal weight but positive for other CVD risk factors 2. overweight without obesity-associated conditions | Lifestyle: Based on long-standing behavioral patterns, maintained by social environment Content: Focus on behavior change; didactic education & additional support; audit & feedback on progress; strategies for self-monitoring, plan for follow-up Incorporate at least 2 behavior change strategies: Match with patient's needs; other evidence-based effective behavior change techniques; define rationale for techniques included; evaluate novel techniques (limited evidence) Individualized counseling & care plan: patient-centered care as basis for motivation & commitment | OW 4 LSt 1 OW 1 OW 6 |
The use of established (proven) cognitive-behavioral strategies (e.g. motivational interviewing) to facilitate lifestyle change by evoking patient motivation to accept and participate in lifestyle treatments are recommended when designing interventions | Goal setting: Specific, proximal, realistic, personal goals for behavior change/resulting outcomes to achieve/maintaining benefits. Moving forward in small, consecutive steps for changing long-term behavior). Consider achievement of outcomes & review further plans/goals Action planning: Develop & prioritize actions, e.g. PA activity of choice & incorporated in daily life (developing routines & habits) for sustainability & acceptability Problem solving: Well-rehearsed coping plans to prevent/manage relapse, e.g. stimulus control, changes in physical environment Motivational interviewing: Encouraging, enabling, verbal persuasion, modelling exercising behavior, discussing positive effects Other techniques: Self-efficacy (Empower patients by building confidence); Feedback & monitoring (Encourage self-monitoring of behavior/outcomes, provide feedback at regular intervals); Social support (Advise /arrange for social network -family, friends, peers- to provide practical help, emotional support, praise or reward); Cognitive behavioral strategies; Positive reinforcement; Cognitive restructuring; Shared decision-making (between HCP & pat/family) | CVD 3 CVD 5 LSt 3 LCh 4 OW 4 | |
Provider Team-based care | Team-based care with the involvement of multidisciplinary professionals is recommended | Multifaceted approach, supporting: Clinical decision-making, collaboration among providers, patient and family member participation Team composition: Trained professionals—dietician/nutritionist, physiotherapist/exercise professional, health educator, psychologist, GP, nurse, pharmacist, social worker, community health worker Roles & responsibility: Limited evidence on organization of complementary competencies Task shifting and sharing: Adding new staff or changing roles of existing staff, considering licensure and responsibilities. E.g. for delivery in primary health care: Brief lifestyle interventions delivered by PN are more cost-effective than delivered by GP Initiation of treatment & follow-up by credentialed provider (e.g. exercise on GP prescription; further educative/follow-up counseling & progress/adherence assessments by other HCP than clinician (e.g. nurse-directed behavioral management) Communication & coordination among various team members | BP 1 BP 2 CVD 3 CVD 5 CVD 7 |
Involve lay or peer workers to deliver interventions in high risk communities and ensure they are part of a wider team led by health care providers | Involve peers/family in planning, design and delivery of credible appropriate messages and interventions (including helping people to develop practical skills to adopt healthy lifestyle). Management & supervision by professionals | DM 2 | |
Lay/peer workers & HCP should identify and encourage 'community champions' (e.g. religious and community leaders) to promote PA | Encourage lay & peer workers to get other members of their community involved | DM 2 | |
Training | Provide training for all professional practitioners and lay people who are responsible for and/or involved in helping to change people's behavior | Competency & confidence/motivation in: Person-centered care; insight in factors affecting behavior change (incl. psychological, social, cultural & economic) & adverse behaviors; health inequalities; select & tailor appropriate evidence-based interventions; intervention mechanism of action; behavior change techniques; access & refer people to local support services Training model: Focused/structured; based on evidence based content & training models; practice new skills in community/practice, share knowledge amongst peers; identify skills gaps Tailored to: setting, participant's characteristics, focus/priority (integral to main role vs. additional task) | LSt 3 DM 2 BP 1 |
Monitor/assess behavior change practitioners, provide feedback and give time/support to develop and maintain competencies | Monitoring & assessment: Competency frameworks & techniques (audio/video recording, observation tool) to monitor HCP’s knowledge & skills (personal development plans, annual reviews), keep up-to-date Ongoing development: Regular evaluation of outcome & process (e.g. using participant feedback), supported by feedback (oral/written), refresher trainings and clear action plans & goal setting in acquiring the necessary competences | LSt 3 DM 2 | |
Information & education Communi-cation | Provide patient education and clearly communicate in order to encourage the person to participate in reducing their CVD risk | Health education principles: Small, comprehensive amounts, didactic education and additional support, reinforced by resources (e.g. written, web-based, audiovisual materials) Effective communication: Friendly & positive interaction; non-judgmental interaction (e.g. lower SES groups/minority groups), patient-centered; open-ended questions, reflective listening; show empathy Content: Risk assessment; treatment; impact & benefits of behavior change; being more physically active and improving dietary habits; gradual improvements to PA; interventions/services available & how to use them | OW 7 BP 1 LCh 1 |
Exercise prescription by physicians (especially GPs), similar to drug prescription, should be considered for health promotion | CVD 3 | ||
Sensibili-zation | Convey messages to the local population and use community resources to raise awareness and increase accessibility, such as short term community-based educational programs | Lifestyle messages: consistent, clear, culturally appropriate, integrated within other local health promotion campaigns/interventions Tailor messages to local community: Work with local practitioners, role models & peers; address misconceptions acting as a barrier; disseminate locally to groups at higher risk (e.g. low SES) Channels of delivery: Involve local community (e.g. Community-wide campaigns, social media, local newspapers/radio channels/shops & businesses/events, social establishments, educational institutions, workplaces, places of worship, local health care establishments, community organizations) | CVD 3 DM 2 |
Patient-centered care | Tailor interventions for specific groups and individuals in order to ensure interventions meet individual needs, preferences & circumstances and are culturally appropriate (especially in high-risk communities). Social determinants of health should inform optimal implementation of treatment recommendations | Patient participation: At each step, beginning with assessment of ‘readiness to change’ & intention, capability, opportunity & motivation (e.g. if multiple behaviors need to be changed, assess which one the person is most motivated to tackle) Socioeconomic inequalities: determinants for CVD risk. Tailor advice to SES Individualized approach & communication: Assess & address previous experiences, beliefs on perceived ability to change, thoughts, worries, attitudes, knowledge, context (physical, economic & social environment), physical and psychological capacity, skills, obstacles, feelings, stage of motivation, skills, self-confidence, barriers to change, self-image, group norms and level of autonomy & tailor interventions and strategies to meet individual needs | CVD 7 LSt 3 LCh 4 DM 2 OW 7 |
Shared decision-making should guide discussions about the best strategies to reduce CVD risk | Decisions should be collaborative between a clinician and a patient: Engage patients in discussions about personalized CVD risk estimates and their implications for the perceived benefits of preventive strategies (i.e. lifestyle habits & goals); hereby addressing potential barriers to treatment options | CVD 7 | |
Reach a shared understanding with overweight and obese patient about the risks of overweight and obesity and the benefits of weight management | 1. Ask permission to discuss health risks & potential benefits/risks of interventions 2. Explore understanding, knowledge, beliefs, experience, values, family/social network 3. Share information about potential risks based on health status 4. Emphasize the need for ongoing commitment 5. Provide small amounts of information/advice, tailored to individual values/preferences & easy to understand 6. Use teach-back method to confirm shared understanding | OW 4 | |
Self- management | For adults who achieve initial weight loss, strongly recommend the adoption of specific strategies, appropriate to their individual situation, to minimize weight regain | Strategies: Self-monitoring (e.g. regular self-weighing), tracking PA (mHealth/eHealth tools or noting activity in diary), relapse prevention & management (rehearsing action-plans e.g. contacting GP), development of routine, coping, self-care strategies | OW 2 CVD 5 |
For adults, include a self-management and/or self-monitoring approach to monitor their weight, BP, or associated behaviors | NOT stand-alone: Self-management approach as part of multicomponent intervention Self-monitoring of chosen behavior or goal (diet/PA/body weight) at least weekly for therapy adherence | OW 2 OW 7 BP 1 | |
Consider the use of a self-monitoring device/tracking system (e.g. pedometer, mobile apps) to increase adherence to PA | Internet-based programs for goal-setting/reminders; lifestyle diaries | BP 1 LCh 1 OW 7 | |
Setting & referral Primary health care | Managers and health professionals in all primary care settings should ensure that preventing and managing obesity is a priority at both strategic and delivery levels. Dedicated resources should be allocated for action | Brief interventions in PHC | OW 5 |
Community | Use community links, outreach projects and lay or peer workers (from lower SES groups) to deliver interventions | Community-based support: Community health workers assisting HCP & pat by serving as liaisons tot the HC system & lay educators | DM 2 |
Commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed for weight loss, provided there is peer-reviewed published evidence of safety/efficacy | Community schemes/facilities: Support & promote those that improve access to PA, combined with tailored information based on local needs | OW 3 | |
Navigation | Work in partnership to develop cost-effective PA interventions | Multifaceted approaches with linkage between PHC—community—public health & health policy interventions | DM 2 |
Provide (written) information on local, affordable, practical and (culturally) acceptable opportunities for PA | DM 2 | ||
Recognize that people may need support to change their lifestyle. To help them do this, refer them to programs such as exercise referral schemes | If no in-house program available or cost-effective option | LCh 1 | |
Delivery mode | Offer comprehensive lifestyle interventions 1. face-to-face in either individual or group sessions 2. telephone based, either as an alternative or an adjunct to face-to-face intervention, provided it includes personalized feedback from trained practitioner 3. internet-based, either as an alternative or an adjunct to face-to-face intervention, provided it includes personalized feedback from trained practitioner | Providing interventions to groups: Group discussions, group tasks (promoting interaction/bonding), mutual support within the group Remote intervention delivery: If there is evidence of efficacy (e.g. telephone, text messaging, apps, internet) for cost-effectiveness | OW 3 OW 4 LSt 1 |