Provide Support and Appropriate Interventions for Healthier Lifestyles
Key Points:
- There is good evidence supporting specific goals and benefits of increased physical activity, but minimal evidence for the efficacy of most clinical interventions.
- There is good evidence supporting specific goals and benefits of improved nutrition, but minimal evidence for the efficacy of most clinical interventions.
- There is good evidence for the efficacy of systematically identifying and providing brief interventions to all individuals who use or are exposed to tobacco, and offering additional interventions and follow-up, as appropriate.
- There is good evidence for the efficacy of systematically identifying and providing brief interventions to all individuals who engage in hazardous or harmful drinking, as well as those who meet the criteria for alcohol abuse or dependence, and offering additional interventions and follow-up, as appropriate.
Clinical interventions, which reliably support healthier lifestyles, must include the following components:
- Deliver clear, consistent goals and key messages
- Utilize evidence-based, validated assessment instruments
- Be prepared to offer advice and brief counseling to people identified as being likely to benefit
- Be prepared to offer more in-depth intervention or referral to people identified as needing additional services or support
- Have well-developed relationships with community and employer stakeholders
Self-management programs that are based on self-efficacy theory and an emphasis on problem solving, decision-making and confidence building [R] can improve health status. [A]
Individualization of education and interventions can be helpful in assisting patients in the change process, and if face-to-face contact is not possible or feasible, then telephone counseling appears to be effective, as well. [A, D]
The most effective intervention timetables appear to be weekly, or biweekly visits with persons, individually or in groups, with individualized assistance and encouragement to continue to make these healthy behavior changes. [C, D, R]
6a. Increased Physical Activity
Minimum Goals (any improvement is beneficial)
At a minimum, all individuals should get at least an additional 10 minutes of physical activity above what they are already doing each day.
Healthier Behavior Goals
For healthy adults under age 65:
Moderate intensity aerobic exercise 30 minutes per day, five days per week or vigorous intensity aerobic exercise 20 minutes per day, three days per week.
Strength training exercises (8 to 12 repetitions each of 8 to 10 different exercises) two days per week. [R]
Optimal Healthy Behavior Goals
Moderate intensity aerobic exercise 45 minutes every day or 60 minutes most days of the week (300 minutes per week), or 10,000 steps per day, or equivalent.
For information on how to measure your intensity level, please see Appendix B, "Intensity Levels of Physical Activity" in the original guideline document.
Key Messages for Increased Physical Activity
- Positive benefits of increased physical activity include cardiorespiratory fitness, improved blood pressure values, improved lipid profile, increased insulin sensitivity, more effective weight management, improved glycemic control, and helps in alleviating symptoms of depression.
- Because the positive effects of increased physical activity diminish within days of the cessation of exercise, regular activity is necessary.
- Gradually increase levels of physical activity either by increasing duration or frequency.
- It is not true that only high-intensity exercise is beneficial; small but sustained improvements result in significant benefits.
- People who can maintain a regular regimen of longer and more intense activity are likely to derive the greatest benefit.
- Physical activity done intermittently throughout the day (increments of at least 10 min. each) may be as beneficial as longer periods of continuous physical exertion.
- Incorporate small increases in activity (taking stairs, parking farther away, exercising while watching television, and taking short activity breaks) into daily routines. [A, R]
- Mild- to moderate-intensity physical activity (brisk walking), when combined with modest weight loss (5% to 10%), results in substantial risk factor modification.
- Use of a pedometer.
Refer to the original guideline document for information about assessment of physical activity and efficacy of clinical interventions.
6b. Improved Nutrition
Healthier Behavior Goals
Follow the nutritional standards of the U.S. Dietary Guideline:
- Emphasize fruit, vegetables, whole grains, and fat-free or low-fat dairy products
- Include lean meats, poultry, fish, beans, eggs, and nuts
- Limit saturated fats, trans fats, cholesterol, salt (sodium) and sugar [R]
Optimal Healthy Behavior Goals
Follow the nutritional standards of the Mediterranean diet:
- Eat a generous amount of fruits and vegetables
- Consume healthy fats such as olive and canola oil
- Eat small portions of nuts
- Consume very little red meat
- Eat fish on a regular basis
- Drink red wine in moderation* (one 5 oz. serving per day for women, one or two 5 oz. servings per day for men) [D]
*There is no evidence that non-drinkers should begin drinking in order to achieve health benefits; this guideline should not be construed in any way advocating such an interpretation.
Key Messages for Improved Nutrition
- Positive benefits of improved nutrition and weight loss include improved blood pressure values, improved lipid profile, improved cardiac status, increased insulin sensitivity, more effective weight management, and improved glycemic control.
- The primary components of a healthier eating pattern include:
- Adequate caloric intake to maintain or achieve a healthy weight
- Consumption of whole grains instead of refined grains
- 5 to 10 servings daily of a variety of fruit and vegetables
- 2 to 3 servings of fat-free or low-fat dairy products daily
- Limiting fats to less than 30% of total caloric intake, with saturated fats less than 7% of caloric intake
- Avoidance of trans fatty acids
- Aiming for less than 300 mg per day of dietary cholesterol
- Selecting lean sources of protein and limit red meat
- No more than 2,400 mg of sodium per day
Typically an eating pattern associated with less processed foods with emphasis on variety, moderation, portionality, and gradual changes of improvement is more likely to incorporate the above components of a healthier eating pattern. [R]
- Modest weight loss (5% to 10%), when combined with mild- to moderate-intensity** physical activity (brisk walking, bicycling 5 to 9 mph, swimming), results in substantial risk factor modification.
- It is not true that only significant weight loss is beneficial; small but sustained improvements result in significant benefits.
- There is no clear evidence that weight cycling is particularly hazardous to health: concerns about cycling should not prevent obese individuals from trying to lose weight. [C]
** See Appendix B, "Intensity Levels of Physical Activity" in the original guideline document for further information on moderate intensity physical activity.
Refer to the original guideline document for information about assessment of nutrition and efficacy of clinical interventions.
See Improved Nutrition Decision Tree for more information.
See the National Guideline Clearinghouse (NGC) summary the Institute for Clinical Systems Improvement (ICSI) guideline Prevention and management of obesity (mature adolescents and adults) for additional information on body mass index and weight management.
6c. Decreased Tobacco Use and Exposure
Minimum goals (any improvement is beneficial)
At a minimum, identify all individuals who use or are exposed to tobacco and provide a brief intervention to help eliminate or at least decrease their use or exposure.
Healthier Behavior Goals
Identify all individuals who use or are exposed to tobacco and provide brief interventions to all; systematically offer additional interventions, including pharmacotherapy and follow-up, as appropriate.
- Eliminate tobacco advertising and commercial promotion.
- Eliminate tobacco smoke in all public areas, both indoor and outdoors.
- Eliminate youth access to tobacco products
Optimal Healthy Behavior Goals
Eliminate all tobacco use and exposure.
Key Messages to Decrease Tobacco Use and Exposure
- Smoking cessation significantly improves health outcomes.
- Advise all females of childbearing age of the harmful effects of smoking on a fetus and the need for cessation during pregnancy.
- Avoiding tobacco smoke improves health, and quitting smoking at any time improves health.
- Avoid any and all tobacco smoke.
- Do not allow smoking at home, in the family vehicles, or in personal workspaces.
- Telephone quit lines, pharmacotherapy, and other interventions are moderately effective in helping to quit smoking.
Assessment of Tobacco Use and Exposure
It is essential that clinicians and health care delivery systems (including administrators, insurers and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting. [R]
Efficacy of Clinical Interventions
Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence.
Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments:
- Patients willing to try to quit tobacco use should be provided with treatments identified as effective in this guideline.
- Patients unwilling to try to quit tobacco use should be provided with a brief intervention designed to increase their motivation to quit.
See Decreased Tobacco Use and Exposure Decision Tree for more information.
Brief Interventions
Brief interventions consist of feedback of screening data designed to increase motivation to change tobacco use behavior, simple advice, health education, goal-setting, practical suggestions, and follow-up, with referral when appropriate. See also Annotation #5, "Collaborative Decision-Making and Brief Interventions."
Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment. [R]
Other Interventions
Tobacco telephone quit lines and proactive telephone counseling increase the odds of abstinence by about 20 percent.
Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation:
- Provision of practical counseling (problem-solving/skills training)
- Provision of social support as part of treatment (intratreatment social support)
- Help in securing social support outside of treatment (extratreatment social support)
Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.
Refer to the original guideline document for more information.
6d. Decreased Hazardous and Harmful Drinking/Alcohol Use
Minimum Goals (any improvement is beneficial)
At a minimum, identify all individuals who engage in hazardous or harmful drinking/alcohol use, as well as those who meet the criteria for alcohol abuse or dependence, and provide an appropriate brief intervention.
Healthier Behavior Goals
Identify all individuals who engage in hazardous or harmful drinking/alcohol use, as well as those who meet the criteria for alcohol abuse or dependence, and provide brief interventions to all; systematically offer additional interventions and follow-up, as appropriate.
Refrain from hazardous drinking (defined by the number of standard drinks any drink that contains 14 grams of pure alcohol—for example: 12 ounces beer or 5 ounces table wine—in a given time period):
- Healthy men (less than 65 years): No more than 14 drinks per week and no more than 4 drinks per occasion
- Healthy women (and healthy men over 65 years): No more than 7 drinks per week and no more than 3 drinks per occasion [R]
Optimal Healthy Behavior Goals
Discontinue all drinking that has any adverse impact on a person's health.
Key Messages to Decrease Hazardous and Harmful Drinking/Alcohol Use
- Several conditions or chronic diseases, including hypertension, trauma, certain cancers and mental health issues, among others, may be positively impacted by decreasing hazardous or harmful levels of drinking.
- Advise all females of childbearing age of the harmful effects of alcohol on a fetus and the need for cessation during pregnancy.
- Reinforce dangers of drinking and driving automobiles, motorcycles, snowmobiles, off-road vehicles, and watercraft.
- Advise patients not to ride with anyone who is under the influence of alcohol and discourage others from driving or operating watercraft while under the influence of alcohol.
Assessment of Harmful and Hazardous Drinking
The AUDIT (the Alcohol Use Disorders Identification Test) tool is the screening instrument best validated for the effective assessment of hazardous or harmful drinking; it can help identify people who would benefit from reducing or ceasing drinking, and give an indication of future alcohol-related problems. The well-known CAGE questions, and others, are designed to screen for alcohol abuse and dependence, but are too narrowly focused to detect individuals in earlier stages of excess alcohol use.
In addition to the screening done as part of a health risk assessment, screening for excessive drinking should also be routinely done for these patients.
- General hospital patients (especially those with disorders known to be associated with alcohol dependence—pancreatitis, cirrhosis, gastritis, tuberculosis, cardiomyopathy)
- Certain persons with psychiatric illness, particularly those who are depressed or who attempt suicide
- Trauma victims in emergency departments
- Homeless persons
- Prisoners
- Persons cited for legal offenses connected with drinking (driving under the influence [DUI], public intoxication, etc.)
The benefits of screening and assessment include:
- Educating patients about appropriate levels of alcohol use and the risks associated with excessive use
- Aiding in the understanding of a patient's presenting symptoms, diagnosis, or lack of response to treatment
- Alerting clinicians about alcohol-drug interactions
Efficacy of Clinical Interventions
Brief Interventions
Brief interventions consist of feedback of screening data designed to increase motivation to change drinking behavior, simple advice, health education, goal-setting, practical suggestions, and follow-up, with referral when appropriate. See also Annotation #2, "Redesign for Results (R4R): Patient-Centered Systems for Healthier Lifestyles."
Interventions based on AUDIT scores are as follows:
- Low-risk drinking or abstinence (AUDIT score 0-7); alcohol education is recommended
- Hazardous drinking (AUDIT score 8-15): simple advice and patient education materials are recommended (see key messages)
- Harmful drinking (AUDIT score 16-19): simple advice, plus brief counseling and continued monitoring are suggested
- Alcohol dependence (AUDIT score 20-40): a referral to a specialist for diagnostic evaluation and treatment should be initiated [R]
Refer to the original guideline document for information on other interventions.