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Archived Final Recommendation Statement

Healthy Diet: Counseling Adults with CVD, January 2003

Originally published on: December 30, 2013

This recommendation statement is currently archived and inactive. It should be used for historical purposes only. Click here for copyright and source information .

Disclaimer:Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Archived: Recommendation Summary

Summary of Recommendations

PopulationRecommendationGrade
(What's This?)
Adults with Hyperlipidemia and Other Risk Factors for CVD

The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. 

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Archived: Preface

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on behavioral counseling in primary care to promote a healthy diet for adults at increased risk for diet-related chronic disease. The recommendation for unselected adults (i.e., those who are not at increased risk) was updated in 2012 and is available here.

 

Archived: Rationale

The USPSTF found good evidence that medium- to high-intensity counseling interventions can produce medium-to-large changes in average daily intake of core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables) among adult patients at increased risk for diet-related chronic disease. Intensive counseling interventions that have been examined in controlled trials among at-risk adult patients have combined nutrition education with behavioral dietary counseling provided by a nutritionist, dietitian, or specially trained primary care clinician (e.g., physician, nurse, or nurse practitioner).

The USPSTF concluded that such counseling is likely to improve important health outcomes and that benefits outweigh potential harms. No controlled trials of intensive counseling in children or adolescents that measured diet were identified.5, 6

Archived: Clinical Considerations

  • Several brief dietary assessment questionnaires have been validated for use in the primary care setting.7, 8 These instruments can identify dietary counseling needs, guide interventions, and monitor changes in patients' dietary patterns. However, these instruments are susceptible to the bias of the respondent. Therefore, when used to evaluate the efficacy of counseling, efforts to verify self-reported information are recommended since patients receiving dietary interventions may be more likely to report positive changes in dietary behavior than control patients.9-12
  • Effective interventions combine nutrition education with behaviorally-oriented counseling to help patients acquire the skills, motivation, and support needed to alter their daily eating patterns and food preparation practices. Examples of behaviorally-oriented counseling interventions include teaching self monitoring, training to overcome common barriers to selecting a healthy diet, helping patients to set their own goals, providing guidance in shopping and food preparation, role playing, and arranging for intra treatment social support. In general, these interventions can be described with reference to the 5-A behavioral counseling framework13:
    1. Assess dietary practices and related risk factors.
    2. Advise to change dietary practices.
    3. Agree on individual diet change goals.
    4. Assist to change dietary practices or address motivational barriers.
    5. Arrange regular followup and support or refer to more intensive behavioral nutritional counseling (e.g., medical nutrition therapy) if needed.
  • Two approaches appear promising for the general population of adult patients in primary care settings:
    1. Medium-intensity face-to-face dietary counseling (two to three group or individual sessions) delivered by a dietitian or nutritionist or by a specially trained primary care physician or nurse practitioner.
    2. Lower-intensity interventions that involve 5 minutes or less of primary care provider counseling supplemented by patient self-help materials, telephone counseling, or other interactive health communications.

    However, more research is needed to assess the long-term efficacy of these treatments and the balance of benefits and harms.

  • The largest effect of dietary counseling in asymptomatic adults has been observed with more intensive interventions (multiple sessions lasting 30 minutes or longer) among patients with hyperlipidemia or hypertension, and among others at increased risk for diet-related chronic disease. Effective interventions include individual or group counseling delivered by nutritionists, dietitians, or specially trained primary care practitioners or health educators in the primary care setting or in other clinical settings by referral. Most studies of these interventions have enrolled selected patients, many of whom had known diet-related risk factors such as hyperlipidemia or hypertension. Similar approaches may be effective with unselected adult patients, but adherence to dietary advice may be lower, and health benefits smaller, than in patients who have been told they are at higher risk for diet-related chronic disease.14
  • Office-level systems supports (prompts, reminders, and counseling algorithms) have been found to significantly improve the delivery of appropriate dietary counseling by primary care clinicians.15-17
  • Possible harms of dietary counseling have not been well defined or measured. Some have raised concerns that if patients focus only on reducing total fat intake without attention to reducing caloric intake, an increase in carbohydrate intake (e.g., reduced-fat or low-fat food products) may lead to weight gain, elevated triglyceride levels, or insulin resistance. Nationally, obesity rates have increased despite declining fat consumption, but studies did not consistently examine effects of counseling on outcomes such as caloric intake and weight.
  • Little is known about effective dietary counseling for children or adolescents in the primary care setting. Most studies of nutritional interventions for children and adolescents have focused on non-clinical settings (such as schools) or have used physiologic outcomes such as cholesterol or weight rather than more comprehensive measures of a healthy diet.5, 6

Archived: Scientific Evidence

Epidemiology and Clinical Consequences

Consuming a healthy diet is associated with lower risks for chronic disease morbidity and mortality. Four of the 10 leading causes of death—coronary heart disease, some types of cancer, stroke, and type 2 diabetes—are associated with unhealthy diets.2 The relationships between dietary patterns and health outcomes have been examined in a wide range of observational studies and randomized trials with patients at risk for diet-related chronic disease. The majority of studies show that people consuming diets that are low in fat, saturated fat, trans-fatty acids, and cholesterol and high in fruits, vegetables, and whole grain products containing fiber have lower rates of morbidity and mortality from coronary heart disease, and possibly several forms of cancer. In addition, one needs to balance calories with physical activity to maintain a healthy weight. The Dietary Guidelines for Americans18 recommend 3 to 5 daily servings of vegetables and vegetable juices, 2 to 4 daily servings of fruits and fruit juices, and 6 to 11 daily servings of grain products, depending on caloric needs. In addition, they recommend a diet that contains less than 10 percent of calories from saturated fat, no more than 30 percent of calories from total fat, and limited consumption of trans-fatty acids.

Despite well-established benefits of consuming a healthy diet, more than 80 percent of Americans of all ages eat fewer than the recommended number of daily servings of fruit, vegetables, and grain products and more than the recommended proportions of daily calories from saturated fat and total fat.19 In 1994-96, 28 percent of people aged 2 years and older consumed at least two daily servings of fruit, 49 percent consumed at least three daily servings of vegetables, 51 percent consumed at least six daily servings of grain products, 36 percent consumed less than 10 percent of daily calories from saturated fat, and 33 percent consumed 30 percent or less of daily calories from total fat.19

Dietary counseling practices of primary care clinicians indicate limited attention to diet modification. In a 1999-2000 survey of U.S. adults, 33 percent of respondents reported past year physician advice to eat more fruits and vegetables, and 29 percent reported similar advice to reduce dietary fat.20 In another recent survey, 25 percent of adult patients from four community based group family medicine clinics indicated that their physicians had advised them to limit or reduce the amount of fat in their diets.21

Effectiveness of Dietary Counseling

The ideal evidence to support behavioral dietary counseling would link counseling directly to improved health outcomes in randomized controlled clinical trials. In the absence of such evidence, the clinical logic behind counseling is based on a chain of critical assumptions13:

  • The clinician must be able to assess whether a patient is consuming a healthy diet.
  • Critical components of counseling must be routinely replicable.
  • Counseling must lead to sustained improvements in diet.
  • The health benefits of these changes in diet must be established and known to exceed the potential harms of intervention.

A review conducted for the USPSTF identified 21 fair-to-good quality randomized controlled clinical trials of dietary counseling among patients without existing diet-related chronic disease (e.g., coronary heart disease or cancer). Trials had to include followup of at least 3 months after intervention for at least 50 percent of the enrolled subjects and include measures of dietary intake. Studies that assessed only physiologic measures (e.g., lipid levels, weight, or body mass index [BMI]) were not included. Additional details of the inclusion and exclusion criteria, and methods for assessing quality of studies, are described elsewhere.2, 22

Most of these trials focused exclusively on dietary counseling, though some targeted diet as part of a broader risk factor modification program that also addressed smoking and sedentary lifestyle.23-26 Most studies targeted reductions in total fat or saturated fat intake (n=17).9-11, 15-17, 23-35 Ten studies targeted increased fruit and vegetable intake10, 11, 14, 23, 27-29, 34, 36, 37 and 7 targeted increased intake of fiber and whole grains.9, 15, 24, 28, 29, 34, 38 Most studies (n=11) focused on a single nutrient, although 10 focused on changes in 2 or more nutrients.9-11, 15, 23, 24, 27-29, 34

Studies were classified by intensity of the interventions evaluated, based on the number and length of counseling sessions, the magnitude and intensity of educational materials provided, and the use of supplemental interventions such as support group sessions or cooking classes. Low-intensity interventions involved one contact lasting less than 30 minutes. High-intensity interventions involved more than six contacts lasting more than 30 minutes. Medium-intensity interventions fell between low- and high-intensity.

Effects of counseling were classified as "large," "medium," or "small" for each component of diet measured.2 With reference to these specific, defined categories, the USPSTF concluded that large effects sustained over time were likely to produce important health benefits (reductions in morbidity and mortality).39-43 Given the large attributable risk associated with these dietary components, it is possible that medium or even small changes in diet would yield important health benefits across a large population. However, to date, there is little direct evidence about the effect of small and medium dietary changes on the future risk for coronary heart disease, making it difficult to determine with certainty whether such changes will translate into changes in the incidence of chronic disease. Better data about these linkages are needed.

Assessing Dietary Behaviors in Primary Care Patients

A number of brief, validated dietary assessment instruments can identify dietary counseling needs, guide intervention, and monitor change among adult patients in primary care and other clinical settings. Most of these instruments can be self-administered, are easily scored, have fewer than 40 items, and take 10 minutes or less to administer. However, these instruments are susceptible to bias (i.e., patients report healthier diets than they actually consume); some studies indicate that under-reporting of caloric intake is common, especially among obese patients.12 When used to evaluate counseling efficacy, efforts to verify self-reported information are recommended.9-12, 15, 26, 44 For children aged 9 years and older, food frequency questionnaires administered directly to children can provide a reasonably accurate picture of usual dietary patterns, with correlations with criterion measures ranging from 0.46 to 0.79.8 No brief valid dietary screening instruments were identified for children below the age of 9 years. The optimal interval for screening adults or children is not known.

Effectiveness of Routine Counseling in Primary Care

The USPSTF found nine fair-to-good quality randomized controlled trials of behavioral dietary counseling in unselected populations in primary care settings. The majority of these interventions focused on change in more than one nutrient (i.e., fat/saturated fat, fruit/vegetables, and/or fiber).9, 11, 15, 27-29, 34 Most of these trials combined basic nutrition education with behaviorally-oriented counseling to help patients acquire the skills, motivation, or support needed to alter their daily eating patterns and food selection and preparation practices. Duration of interventions lasted from 1 week to 1 year. No controlled trials with children or adolescents were identified.

The nine studies varied in the amount of face-to-face counseling involved. Two studies of medium-intensity interventions evaluated multiple face-to-face sessions of behavioral dietary counseling provided in the primary care setting by a dietitian or nutritionist, or by a primary care physician or nurse practitioner who had received brief training in dietary counseling.34, 38 These interventions involved two to three group or individual sessions lasting 30 minutes, with followup visits at 1 and 3 months. Baron et al. reported an 84 percent patient recruitment/participation rate.38

Seven studies involved little or no face-to-face counseling and placed greater emphasis on patient self-help materials, manuals, and varied forms of interactive health communication. Two were studies of low-intensity interventions that combined brief (≤5 minutes) face-to-face counseling sessions with a primary care physician or nurse with self-help materials.9, 15 Three others were studies of low-intensity interventions that relied either on mailed self-help materials27, 36 or on health behavior change messages delivered via an automated computer-based voice system.29 Campbell et al.27 found significantly greater benefits from tailored than non-tailored self-help materials; Lutz et al.36 did not. The remaining two were medium-intensity interventions that combined a computer-generated personalized letter and motivational phone call(s) from a trained health educator with a series of self-help mailings and newsletters.11, 28 Patient recruitment and participation in this second group of studies ranged from 16 percent36 to 80 percent,27 with most in the 40 percent to 70 percent range.

These studies in unselected populations produced mostly small (n = 9) and medium (n = 8) as opposed to large (n = 3) improvements in self-reported dietary behaviors, most of which were statistically significant. Most studies followed patients for 6 months or less post-intervention; four followed patients for as long as 12 months.11.15.34.38 Only two of them assessed impacts on intermediate biological endpoints (e.g., serum cholesterol, weight, or BMI), of which none reported significant treatment effects.15, 38 No studies examined adverse treatment effects.

The USPSTF also reviewed two additional studies that enrolled predominantly healthy premenopausal women, a large proportion of whom were overweight or obese. These studies employed high-intensity interventions involving multiple dietitian-led individual14 or group35 counseling sessions. One intervention extended over a 6-month period and aimed at increasing fruit and vegetable intake14; the other extended over a 5-year period and focused on dietary fat reduction. Both trials reported large treatment effects in self-reported dietary behavior at 6-month post-intervention followup, and both reported favorable changes in biological risk factors or markers. However, participants in these studies were highly selected and motivated volunteers. The USPSTF concluded that results could not be generalized to more representative primary care populations.

Effectiveness of Intensive Counseling in Patients at Risk for Chronic Disease

The USPSTF found 10 fair-to-good quality randomized controlled trials that tested whether medium- to high-intensity interventions delivered in primary care or other clinical settings led to improved dietary outcomes among adults who were identified as being at increased risk for diet-related chronic disease.10, 16, 17, 23-26, 30-33, 37 For two of these trials, two research reports for each were reviewed.16-17, 30-31 No controlled trials with children or adolescents at risk for chronic disease were identified that reported dietary outcomes.

The interventions involved a two-step assessment: screening to identify a patient's risk status using chart audit/clinical exam/laboratory testing to screen for hyperlipidemia, hypertension, family history of heart disease or breast cancer, overweight, obesity, smoking status, and sedentary lifestyle, followed by assessment of dietary practices using a variety of dietary assessment tools and protocols (e.g., food frequency questionnaires, 3-4-day food records, and brief dietary assessment instruments). Hyperlipidemia was included as a risk factor in most of these studies. Four trials addressed diet along with physical activity and/or smoking.23-26

Most of the trials tested multi-session group or individual counseling that combined nutrition education with behaviorally-oriented counseling. Most studies focused on reducing saturated fat and/or total fat intake; two of these studies also targeted fiber or fruit and vegetable intake,23, 24 and one focused on increasing fruit and vegetable intake only.37 Most studies also reported intermediate health outcomes, such as serum lipid levels, blood pressure, weight, and/or BMI. Followup in most studies (n=6) was 12 months or longer, some as long as 4 to 6 years.23-26, 30-32

Six of the trials took place outside of primary care settings, where counseling was provided by an experienced nutritionist, dietitian, and/or health educator in 8 to 20 sessions over a period ranging from 4 months to 5 to 6 years.10, 23, 25, 30, 31, 33, 37 Four trials took place in primary care settings,16, 17, 24, 26, 32 where counseling was provided by specially trained primary care physicians or nurses (training ranging from 60 minutes to 3 days) in three to six special sessions supplemented by followup phone calls and/or newsletters, and followup at routine visits over a period of 4 to 18 months. In two primary care-based studies,16, 17, 32 behavioral dietary counseling for patients with hyperlipidemia was supplemented, if needed, with lipid-lowering medication and/or referral to outside counseling by a dietitian. Ockene et al.17 found that implementing office-level systems supports (prompts, reminders, and counseling algorithms) significantly improved primary care provider adherence to the comprehensive dietary counseling.

In summary, interventions for patients at risk for chronic disease resulted in dietary behavior changes that were small (n=3),16, 17, 23, 24 medium (n=6),10, 23, 24, 26, 32, 37 and large (n=4),10, 25, 30, 33 most of which were statistically significant. The magnitude and duration of these changes were greater with higher intensity interventions than with interventions of lower-intensity. More than one-half of these studies found that self-reported dietary changes were accompanied by significant improvements in serum lipids, weight, or BMI.10, 23, 24, 30-32 These findings help corroborate patients' self-reported dietary changes and confirm the overall health benefits of the observed changes in diet.

Archived: Discussion

Medium- to high-intensity behavioral interventions appear to produce consistent, sustained, and clinically important changes in dietary intake of total fat, saturated fat, fruit and vegetables, and fiber. However, these trials were generally either conducted with patients with known risk factors for diet-related chronic disease, or performed in special clinics with highly selected patients and specially trained providers. The most effective interventions generally combined education, behaviorally-oriented counseling, and patient reinforcement and followup. More intensive interventions, and those of longer duration, are associated with larger magnitude of benefit and more sustained changes in diet.

Available studies do not, however, allow firm conclusions about the essential or most effective elements of these multi-component interventions, their relative effect on specific dietary constituents (e.g., fat, fruit and vegetables, or fiber), or the relative efficacy of targeting single or multiple dietary risks or addressing diet in the context of broader lifestyle interventions. Although evidence is stronger for counseling patients who are at increased risk for chronic disease, such as those with hyperlipidemia, than for the general population of patients, it is not possible to disentangle the effects of patient risk status from the effects of intervention intensity. Adherence to these intensive interventions and the dietary changes they require may be dependent on patients' heightened perceived risk and motivation for change.

Existing trials of routine dietary interventions in unselected primary care populations have generally produced only small-to-medium changes in self-reported diet. Although direct comparisons cannot be made, results from medium-intensity, routine face-to-face counseling from nutritionists, dietitians, or specially trained primary care practitioners (physicians, nurses, or nurse practitioners) appear similar to those achieved through less intensive, minimal-contact interventions to supplement brief primary care provider advice/counseling. The consistently positive effects of such interventions on diet in unselected patient populations establish these interventions as highly promising as part of routine preventive care for patients at average risk for chronic disease.

The USPSTF concluded, however, that existing studies do not provide sufficient evidence to recommend these interventions for widespread use due to a number of limitations such as modest overall patient recruitment/participation rates, reliance on self-reported outcome measures, relatively short followup periods, uncertainty about the health effects of small and medium changes in diet, and the lack of evidence about possible adverse effects of counseling. Two studies suggest high-intensity interventions can be effective in selected patients at average risk, but the applicability of these findings and the feasibility of these interventions in primary care settings are uncertain.14, 35

Archived: Recommendations of Others

Dietary guidelines for the general population have been issued by the U.S. Department of Agriculture (USDA)18 and the Department of Health and Human Services; specific dietary objectives for the nation are outlined in Healthy People 2010.19 Guidelines from the American Heart Association (AHA) and the American Cancer Society (ACS) address diets that will lower the risk for heart disease and cancer, respectively.45, 46 These guidelines generally agree in recommending a diet that includes a variety of fruit, vegetables, and grain products; is low in saturated fat and cholesterol and moderate in total fat; and balances calories with physical activity to maintain a healthy weight.

A variety of groups have recommended nutritional counseling or dietary advice for patients at average risk for chronic disease, including the American College of Preventive Medicine (ACPM), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG).47-50 These recommendations are based primarily on the benefits of a healthy diet rather than on evaluations of the efficacy of counseling. The Canadian Task Force on Preventive Health Care (CTFPHC) concluded in 1994 that there was fair evidence to provide general dietary advice to all patients, based on a limited number of trials of counseling.51

Recommendations on nutritional counseling for patients at risk (e.g., those who have hypertension or hyperlipidemia) have been issued by the American Dietetic Association (ADA) and two panels sponsored by the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute. The ADA recommends that primary care providers screen for nutrition-related illnesses, prescribe diets, provide preliminary counseling on specific nutritional needs, follow up with patients, and refer patients to appropriate dietetic professionals when necessary.52 Similarly, The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends that dietary assessments be included as part of routine medical history and that physicians counsel patients on lifestyle modifications for the prevention and treatment of high blood pressure (lose weight if overweight, limit alcohol intake, reduce sodium intake, reduce saturated fat and cholesterol intake).53 The National Cholesterol Education Program recommends that individuals with elevated levels of low density lipoprotein limit their intake of fats, particularly saturated fats, and cholesterol and increase dietary fiber.54

 

Archived: Members of the U.S. Preventive Services Task Force

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland Baltimore, Baltimore, MD); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H.* (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H.* (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc.* (Clinical Professor and Director, Department of Medicine, University of Texas Health Science Center, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist and Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H.* (Director of Research, Women and Infants' Hospital, Providence, RI); Nola J. Pender, Ph.D., R.N.* (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor of Obstetrics and Gynecology and Professor of Public Health, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine, Fairfax, VA).

* Member of the USPSTF at the time this recommendation was finalized.

Archived: Notes

This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.uspreventiveservicestaskforce.org.

Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.

Source: This recommendation first appeared in Am J Prev Med 2003;24(1):93-100.

References:
  1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996.
  2. Ammerman A, Pignone M, Fernandez L, et al. Counseling to Promote a Healthy Diet. Systematic Evidence Review No. 18 (Prepared by Research Triangle Institute-University of North Carolina Evidence-Based Practice Center under Contract No. 290-97-011). Rockville, MD: Agency for Healthcare Research and Quality. April 2002. Available at: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hscps2ed1996&part=A15693.
  3. McTigue K, Harris R, Hemphill MB, Bunton A. Screening and Interventions for Overweight and Obesity in Adults. Systematic Evidence Review. Rockville, MD: Agency for Healthcare Research and Quality (in press).
  4. Pignone MP, Phillips CJ, Lannon CM, et al. Screening for Lipid Disorders. Systematic Evidence Review No. 4 (Prepared by Research Triangle Institute-University of North Carolina Evidence-Based Practice Center under Contract No. 290-97-011). Rockville, MD: Agency for Healthcare Research and Quality. April 2001. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.chapter.1293
  5. Obarzanek E, Hunsberger SA, Van Horn L, et al. Safety of a fat-reduced diet: the Dietary Intervention Study in Children (DISC). Pediatrics 1997;100(1):51-59.
  6. Obarzanek E, Kimm SY, Barton BA, et al. Long-term safety and efficacy of a cholesterol-lowering diet in children with elevated low-density lipoprotein cholesterol: seven-year results of the Dietary Intervention Study in Children (DISC). Pediatrics 2001;107(2):256-264.
  7. Calfas KJ, Zabinski MF, Rupp J. Practical nutrition assessment in primary care settings: a review. Am J Prev Med 2000;18(4):289-299.
  8. Rockett HR, Colditz GA. Assessing diets of children and adolescents. Am J Clin Nutr 1997;65(4):1116-1122.
  9. Beresford SA, Farmer EM, Feingold L, Graves KL, Sumner SK, Baker RM. Evaluation of a self-help dietary intervention in a primary care setting. Am J Public Health 1992;82(1):79-84.
  10. Coates RJ, Bowen DJ, Kristal AR, et al. The Women's Health Trial Feasibility Study in Minority Populations: changes in dietary intakes. Am J Epidemiol 1999;149(12):1104-1112.
  11. Kristal AR, Curry SJ, Shattuck AL, Feng Z, Li S. A randomized trial of a tailored, self-help dietary intervention: the Puget Sound Eating Patterns study. Prev Med 2000;31(4):380-389.
  12. Little P, Barnett J, Margetts B, et al. The validity of dietary assessment in general practice. J Epidemiol Commun Health 1999;53(3):165-172.
  13. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002;22(4):267-284.
  14. Maskarinec G, Chan CL, Meng L, Franke AA, Cooney RV. Exploring the feasibility and effects of a high-fruit and -vegetable diet in healthy women. Cancer Epidemiol Biomarkers Prev 1999;8(10):919-924.
  15. Beresford SA, Curry SJ, Kristal AR, Lazovich D, Feng Z, Wagner EH. A dietary intervention in primary care practice: the Eating Patterns Study. Am J Public Health 1997;87(4):610-616.
  16. Ockene IS, Hebert JR, Ockene JK, et al. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Int Med 1999;159(7):725-731.
  17. Ockene IS, Hebert JR, Ockene JK, Merriam PA, Hurley TG, Saperia GM. Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH). Am J Prev Med 1996;12(4):252-258.
  18. U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, Fifth Edition (2000). Available at http://www.health.gov/dietaryguidelines/. Accessed November 15, 2002.
  19. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000. Available online at: http://www.health.gov/healthypeople/.
  20. Glasgow RE, Eakin E.G., Fisher EB, Bacak SJ, Brownson RC. Physician advice and support for physical activity: results from a national survey. Am J Prev Med 2001;21(3):189-196.
  21. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behaviours? Arch Fam Med 2000;9:426-433.
  22. Harris R, Helfand M, Woolf S, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20(suppl 3):21-35.
  23. Knutsen SF, Knutsen R. The Tromso Survey: the Family Intervention study—the effect of intervention on some coronary risk factors and dietary habits, a 6-year followup. Prev Med 1991;20(2):197-212.
  24. Lindholm LH, Ekbom T, Dash C, Eriksson M, Tibblin G, Schersten B. The impact of health care advice given in primary care on cardiovascular risk. CELL Study Group. BMJ 1995;310(6987):1105-1109.
  25. Neaton JD, Broste S, Cohen L, Fishman EL, Kjelsberg MO, Schoenberger J. The multiple risk factor intervention trial (MRFIT). VII. A comparison of risk factor changes between the two study groups. Prev Med 1981;10(4):519-543.
  26. Steptoe A, Doherty S, Rink E, Kerry S, Kendrick T, Hilton S. Behavioural counseling in general practice for the promotion of healthy behaviour among adults at increased risk of coronary heart disease: randomised trial. BMJ 1999;319(7215):943-947; discussion 947-948.
  27. Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandler RS. Improving dietary behavior: the effectiveness of tailored messages in primary care settings. Am J Public Health 1994;84(5):783-787.
  28. Delichatsios HK, Hunt MK, Lobb R, Emmons K, Gillman MW. EatSmart: efficacy of a multifaceted preventive nutrition intervention in clinical practice. Prev Med 2001;33(2 Pt 1):91-98.
  29. Delichatsios HK, Friedman RH, Glanz K, et al. Randomized trial of a 'talking computer' to improve adults' eating habits. Am J Health Promot 2001;15(4):215-224.
  30. Henderson MM, Kushi LH, Thompson DJ, et al. Feasibility of a randomized trial of a low-fat diet for the prevention of breast cancer: dietary compliance in the Women's Health Trial Vanguard Study. Prev Med 1990;19(2):115-133.
  31. Insull WJ, Henderson MM, Prentice RL, et al. Results of a randomized feasibility study of a low-fat diet. Arch Intern Med 1990;150(2):421-427.
  32. Keyserling TC, Ammerman AS, Davis CE, Mok MC, Garrett J, Simpson RJ. A randomized controlled trial of a physician-directed treatment program for low-income patients with high blood cholesterol: the Southeast Cholesterol Project. Arch Fam Med 1997;6(2):135-145.
  33. Mojonnier ML, Hall Y, Berkson DM, et al. Experience in changing food habits of hyperlipidemic men and women. J Am Diet Assoc 1980;77(2):140-148.
  34. Roderick P, Ruddock V, Hunt P, Miller G. A randomized trial to evaluate the effectiveness of dietary advice by practice nurses in lowering diet-related coronary heart disease risk. Br J Gen Pract 1997;47(414):7-12.
  35. Simkin-Silverman LR, Wing RR. Management of obesity in primary care. Obesity Research 1997;5(6):603-612.
  36. Lutz SF, Ammerman AS, Atwood JR, Campbell MK, DeVellis RF, Rosamond WD. Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults. J Am Diet Assoc 1999;99(6):705-709.
  37. Siero FW, Broer J, Bemelmans WJ, Meyboom-de Jong BM. Impact of group nutrition education and surplus value of Prochaska- based stage-matched information on health-related cognitions and on Mediterranean nutrition behavior. Health Educ Res 2000;15(5):635-647.
  38. Baron JA, Gleason R, Crowe B, Mann JI. Preliminary trial of the effect of general practice based nutritional advice. Br J Gen Pract 1990;40(333):137-141.
  39. Ascherio A, Hennekens C, Willett WC, et al. Prospective study of nutritional factors, blood pressure, and hypertension among US women. Hypertension 1996;27(5):1065-1072.
  40. Bazzano LA, He J, Ogden LG, et al. Legume consumption and risk of coronary heart disease in US men and women: NHANES I Epidemiologic Followup Study. Arch Intern Med 2001;161(21):2573-2578.
  41. Jacobs DR, Pereira MA, Meyer KA, Kushi LH. Fiber from whole grains, but not refined grains, is inversely associated with all-cause mortality in older women: the Iowa women's health study. J Am Coll Nutr 2000;19(suppl 3):326S-330S.
  42. Joshipura KJ, Hu FB, Manson JE, et al. The effect of fruit and vegetable intake on risk for coronary heart disease. Ann Intern Med 2001;134(12):1106-1114.
  43. Liu S, Manson JE, Stampfer MJ, et al. Whole grain consumption and risk of ischemic stroke in women: A prospective study. JAMA 2000;284(12):1534-1540.
  44. Stevens VJ, Glasgow RE, Toobert DJ, Karanja N, Smith KS. Randomized trial of a brief dietary intervention to decrease consumption of fat and increase consumption of fruits and vegetables. Am J Health Promot 2002;16(3):129-134.
  45. Wylie-Rosett J. Fat substitutes and health: an advisory from the Nutrition Committee of the American Heart Association. Circulation 2002;105:2800-2804.
  46. American Cancer Society. Recommendations for nutrition and physical activity for cancer prevention. Available at: http://www.cancer.org. Accessed August 28, 2002.
  47. Nawaz H, Katz DL. American College of Preventive Medicine Policy Statement: weight management counseling of overweight adults. Am J Prev Med 2001:21(1):73-78.
  48. American Academy of Family Physicians. Summary of policy recommendations for periodic health examinations, revision 5.1. Available at: http://www.aafp.org/exam.xml. Accessed August 28, 2002.
  49. American Academy Of Pediatrics. Committee on Nutrition. Policy statement: Cholesterol in Childhood (RE9805). Pediatrics 1998;101(1):141-147. Available at: http://www.aap.org/policy/re9805.html. Accessed August 28, 2002.
  50. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. 2nd ed. Washington, DC: ACOG; 2002:121-34, 196-200.
  51. Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada; 1994:586-599. Available at: http://www.ctfphc.org. Accessed August 28, 2002.
  52. Maillet JO, Young EA. Nutrition education for healthcare professionals: Position of the ADA. J Am Diet Assoc 1998;98:343-346.
  53. Sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Bethesda, MD: National Heart Lung and Blood Institute; 1997. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm. Accessed August 28, 2002.
  54. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, MD: National Heart Lung and Blood Institute; 2001. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm. Accessed August 28, 2002.
Current as of: June 2003

Internet Citation: Final Recommendation Statement: Healthy Diet: Counseling Adults with CVD, January 2003. U.S. Preventive Services Task Force. February 2014.
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/diet-for-adults-at-increased-risk-for-cardiovascul

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