Table 3 Strategies recommended in clinical practice guidelines for the implementation of PA lifestyle advice for the primary prevention of CVD
Field Subfield | Recommendation | Details of recommendation | Guideline reference number (see Table 1 for details) |
|---|---|---|---|
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 | Â | 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 | Â | 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 |