Adults Eligible for Cardiovascular Disease Prevention Counseling and Participation in Aerobic Physical Activity — United States, 2013

John D. Omura, MD1,2; Susan A. Carlson, PhD2; Prabasaj Paul, PhD2; Kathleen B. Watson, PhD2; Fleetwood Loustalot, PhD3; Jennifer L. Foltz, MD3; Janet E. Fulton, PhD2

Cardiovascular disease (CVD) is the leading cause of death in the United States, and physical inactivity is a major risk factor (1). Health care professionals have a role in counseling patients about physical activity for CVD prevention. In August 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that adults who are overweight or obese and have additional CVD risk factors be offered or referred to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention (2). Although the USPSTF recommendation does not specify an amount of physical activity, the 2008 Physical Activity Guidelines for Americans* state that for substantial health benefits adults should achieve ≥150 minutes per week of moderate-intensity aerobic physical activity or ≥75 minutes per week of vigorous-intensity aerobic activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. To assess the proportion of adults eligible for intensive behavioral counseling and not meeting the aerobic physical activity guideline, CDC analyzed data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS). This analysis indicated that 36.8% of adults were eligible for intensive behavioral counseling for CVD prevention. Among U.S. states and the District of Columbia (DC), the prevalence of eligible adults ranged from 29.0% to 44.6%. Nationwide, 19.9% of all adults were eligible and did not meet the aerobic physical activity guideline. These data can inform the planning and implementation of health care interventions for CVD prevention that are based on physical activity.

BRFSS is an annual, random-digit–dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years. The survey is conducted independently in all 50 states and DC, and BRFSS data can be pooled to produce valid national estimates (3). Based on standards set by the American Association of Public Opinions Research,† the median survey response rate for all states and DC in 2013 was 46.4% (range = 29.0%–60.3%). In 2013, data were collected from 483,865 respondents. However, this analysis excluded 75,776 respondents because of missing information.

Respondents were defined as eligible for intensive behavioral counseling for CVD prevention if they were overweight or obese, and had one or more CVD risk factors (hypertension, dyslipidemia, or impaired fasting glucose). Body mass index (BMI) (weight [kg] / height [m]2) was calculated from self-reported weight and height (overweight = BMI 25.0–29.9, obese = BMI ≥30.0). Respondents were defined as having hypertension, dyslipidemia, or impaired fasting glucose if they responded "yes" to a question asking if a doctor, nurse, or other health professional ever told them they had a specific condition (e.g., high blood pressure, high blood cholesterol, diabetes, pre-diabetes, or borderline diabetes).

To assess physical activity, respondents were asked to report the frequency and duration of the two physical activities, outside of regular job duties, that they spent the most time doing during the past month or week. Respondents were classified as meeting the aerobic guideline if they participated in ≥150 minutes per week of moderate-intensity aerobic activity, or ≥75 minutes per week of vigorous-intensity aerobic activity, or an equivalent combination of the two (4). Data were analyzed by demographic characteristics and weighted by iterative proportional fitting (raking) to provide prevalence estimates and 95% confidence intervals. Orthogonal polynomial contrasts and pairwise t-tests were used to identify significant trends and differences by subgroup.

In 2013, an estimated 36.8% of U.S. adults met criteria to be classified as eligible for intensive behavioral counseling for CVD prevention, including 40.0% of men and 33.5% of women (Table 1). By age group, the prevalence of eligibility increased as age increased, from 6.6% among those aged 18–24 years to 56.4% among those aged ≥65 years (p-value for trend <0.001). Among racial/ethnic groups, prevalence was higher among non-Hispanic blacks (43.3%) than among Hispanics (32.6%) (p<0.001) and non-Hispanic whites (37.6%) (p<0.001). By education level, prevalence decreased as education level increased, from 42.3% for persons with less than a high school diploma to 31.8% for college graduates (p-value for trend <0.001).

Among the 50 states and DC, the prevalence of eligible adults ranged from 29.0% in Utah to 44.6% in Tennessee (Table 2). States in the South had the highest proportion of eligible adults (39.4%), compared with the Midwest (36.9%) (p<0.001), the Northeast (36.0%) (p<0.001), and the West (33.2%) (p<0.001) (Table 1).

Among adults who were eligible for intensive behavioral counseling for CVD prevention, 54.0% did not meet the aerobic physical activity guideline (Table 1). By age group, this percentage increased as age increased until it leveled off for adults aged 35–64 years, after which it decreased for adults aged ≥65 years (p-value for trend <0.001). This percentage was significantly higher in men than women; was higher in Hispanics and non-Hispanic blacks than non-Hispanic whites; decreased as education level increased (p-value for trend <0.001); and was greatest in the South and lowest in the West. The percentage of eligible adults who did not meet the aerobic physical activity guideline (54.0% [95% confidence interval = 53.5%–54.5%]) was significantly higher than the percentage of ineligible adults who did not meet the guideline (46.4% [95% confidence interval = 46.0%–46.8%]) (p<0.001).

Of the entire adult population, 19.9% were eligible for intensive behavioral counseling for CVD prevention and did not meet the aerobic physical activity guideline (Table 1). Among the 50 states and DC, the prevalence of being eligible and not meeting the aerobic physical activity guideline ranged from 12.4% in Hawaii to 28.8% in Mississippi (Table 2) (Figure).

Discussion

Approximately one in three U.S. adults were eligible for intensive behavioral counselling for CVD prevention in 2013. State-based estimates of eligible adults ranged from 29.0% to 44.6%. The prevalence of eligibility was higher among men, non-Hispanic blacks, older adults, and persons residing in southern states. Nationwide, an estimated 19.9% of U.S. adults were eligible for intensive behavioral counselling and did not meet the aerobic physical activity guideline, accounting for 54.0% of eligible adults. This group might particularly benefit from physical activity intensive behavioral counseling for CVD prevention.

Primary care providers are well positioned within the health care system to promote preventive health behaviors through activities such as assessment, counseling, and referral. Primary care provider offices are the most common places where clinical care services are provided (5), and advice from these providers influences patient behaviors (6). However, primary care providers face barriers to providing preventive services, including lack of time, limited patient receptiveness, lack of remuneration, and limited counseling skills (7). The Affordable Care Act's preventive services mandate might mitigate some barriers by requiring most health plans to cover evidence-based preventive services with a USPSTF rating of "A" or "B" (8). The USPSTF recommendation for intensive behavioral counseling for CVD prevention received a "B" rating, making it eligible for coverage (2) and improving the potential for implementing intensive behavioral counseling for CVD prevention.

Given the health care system barriers to implementation, monitoring the percentage of eligible adults who receive counseling is important. Existing surveys such as the National Ambulatory Medical Care Survey (NAMCS) and the National Health Interview Survey assess some aspects of physician counseling or providing education about exercise or physical activity, but none can comprehensively assess this USPSTF recommendation. For example, the 2010 NAMCS estimates that 12.3% of office visits made by patients with a diagnosis of CVD, diabetes, or hyperlipidemia involved a clinician's ordering or providing exercise education (9). Although the NAMCS measure identifies a potential gap between persons eligible for behavioral counseling and persons receiving it, it does not directly assess the USPSTF recommendation because it pertains to general education and not intensive behavioral counseling. Further, these data precede the 2014 USPSTF recommendation that establishes the basis for coverage of these services under the Affordable Care Act. Efforts to monitor the implementation of this USPSTF recommendation are needed to document its uptake and impact on health.

The findings in this report are subject to at least five limitations. First, BRFSS data are self-reported and might be susceptible to recall and social-desirability bias. Second, the eligible population might be overestimated because the survey questions asked respondents whether they had ever received a diagnosis and not whether they currently had a diagnosed condition. Third, the low response rates (median = 46.4%) could have resulted in response bias; however, weighting and survey methodology adjust estimates to reduce the effect of nonresponse bias (10). Fourth, because of lack of available data, the inclusion criteria did not include metabolic syndrome; however, inclusion criteria covered individual components of the metabolic syndrome definition. Finally, respondents reported their top two physical activities outside of regular job duties. Some respondents classified as not meeting the aerobic guideline might have been misclassified because information about additional aerobic activities or job duties was not included.

The USPSTF recommendation for intensive behavioral counselling to prevent CVD could benefit a third of the U.S. adult population, especially the one in five adults who did not meet the aerobic physical activity guideline. Because of increased coverage by the Affordable Care Act, this recommendation provides an opportunity for primary care providers to increase provision of such preventive services for this population at risk for CVD. Continued monitoring of the recommendation's target population and implementation, potential barriers, and impact on health behaviors and outcomes will help determine the impact of this recommendation on preventing CVD.

1Epidemic Intelligence Service, CDC; 2Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC; 3Division of Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Corresponding author: John D. Omura, ydk8@cdc.gov, 770-488-6339.

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