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

References

  1. Mozaffarian D, Benjamin EJ, Go AS, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation 2015;131:e29–322.
  2. LeFevre ML, U.S. Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2014;161:587–93.
  3. CDC. Behavioral Risk Factor Surveillance System. BRFSS data quality, validity, and reliability. Available at http://www.cdc.gov/brfss/publications/methodology/data_qvr.htm.
  4. CDC. Adult participation in aerobic and muscle-strengthening physical activities—United States, 2011. MMWR Morb Mortal Wkly Rep 2013;62:326–30.
  5. Shi L. The impact of primary care: a focused review. Scientifica (Cairo) 2012;2012:432892.
  6. Elley CR, Kerse N, Arroll B, Robinson E. Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial. BMJ 2003;326:793.
  7. Eakin EG, Smith BJ, Bauman AE. Evaluating the population health impact of physical activity interventions in primary care—are we asking the right questions? J Phys Act Health 2005;2:197–215.
  8. Fox JB, Shaw FE. Clinical preventive services coverage and the Affordable Care Act. Am J Public Health 2015;105:e7–10.
  9. US Department of Health and Human Services. Healthy People 2020. Available at http://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity.
  10. CDC. Methodologic changes in the Behavioral Risk Factor Surveillance System in 2011 and potential effects on prevalence estimates. MMWR Morb Mortal Wkly Rep 2012;61:410–3.

* Available at http://www.health.gov/paguidelines.

Additional information available at http://www.cdc.gov/brfss/annual_data/annual_2013.html.


Summary

What is already known on this topic?

Health care professionals have a role in counseling patients about physical activity, which can help prevent cardiovascular disease (CVD) among persons with risk factors, such as hypertension, high cholesterol, or impaired fasting glucose. To prevent CVD, the U.S. Preventive Services Task Force recommended in August 2014 that obese and overweight adults with additional CVD risk factors be offered or referred to intensive behavioral counseling interventions to promote a healthful diet and physical activity.

What is added by this report?

Based on 2013 data from a national telephone survey, an estimated 36.8% of U.S. adults were eligible for intensive behavioral counseling for CVD prevention according to new recommendations issued by the U.S. Preventive Services Task Force in 2014. Prevalence of eligibility ranged from 29.0% in Utah to 44.6% in Tennessee. Nationwide, approximately 19.9% of U.S. adults were eligible and did not meet the guideline for aerobic physical activity from the 2008 Physical Activity Guidelines for Americans.

What are the implications for public health practice?

One in five U.S. adults are eligible to receive intensive behavioral counseling for CVD prevention and do not meet the aerobic physical activity guideline and could benefit from increasing their physical activity levels. The Affordable Care Act's preventive services mandate might facilitate the implementation of this preventive intervention.


TABLE 1. Proportion of U.S. adults eligible for intensive behavioral counseling for CVD prevention and not meeting aerobic physical activity guideline, by selected characteristics — Behavioral Risk Factor Surveillance System, United States, 2013

Characteristic

Overall population
(N = 408,089)

Eligible population*
(n = 174,859)

Eligible for intensive
behavioral counseling
for CVD prevention*

Eligible and not meeting
aerobic physical
activity guideline

Not meeting
aerobic physical
activity guideline

%

(95% CI)

%

(95% CI)

%

(95% CI)

Total

36.8

(36.5–37.1)

19.9

(19.6–20.1)

54.0

(53.5–54.5)

Sex

Men

40.0

(39.6–40.5)

20.2

(19.8–20.6)

50.5

(49.7–51.2)

Women

33.5

(33.1–33.9)

19.5

(19.2–19.8)

58.2

(57.5–58.8)

Age group (yrs)

18–24

6.6

(6.1–7.2)

3.4

(3.1–3.8)

51.5

(47.5–55.5)

25–34

16.6

(15.9–17.2)

8.6

(8.1–9.1)

51.9

(49.8–54.1)

35–44

29.4

(28.6–30.1)

16.5

(15.9–17.1)

56.1

(54.6–57.6)

45–54

43.8

(43.0–44.5)

24.4

(23.8–25.1)

55.8

(54.6–56.9)

55–64

55.0

(54.3–55.6)

30.1

(29.5–30.8)

54.8

(53.9–55.8)

≥65

56.4

(55.9–57.0)

29.2

(28.6–29.7)

51.7

(50.9–52.5)

Race/Ethnicity§

White, non-Hispanic

37.6

(37.3–37.9)

19.5

(19.3–19.8)

51.8

(51.3–52.3)

Black, non-Hispanic

43.3

(42.3–44.3)

25.7

(24.8–26.6)

59.4

(57.9–60.9)

Hispanic

32.6

(31.5–33.7)

19.9

(18.9–20.8)

60.9

(58.9–62.9)

Other race

27.1

(25.7–28.4)

14.1

(13.0–15.2)

52.0

(49.0–54.9)

Education level

Less than high school diploma

42.3

(41.2–43.4)

28.1

(27.1–29.1)

66.3

(64.7–67.8)

High school diploma

38.8

(38.2–39.3)

22.5

(22.0–22.9)

57.9

(57.1–58.8)

Some college

36.8

(36.2–37.3)

19.0

(18.6–19.4)

51.6

(50.7–52.5)

College degree

31.8

(31.4–32.3)

13.9

(13.5–14.2)

43.6

(42.8–44.4)

U.S. Census region

Midwest

36.9

(36.3–37.4)

19.5

(19.1–20.0)

52.9

(52.0–53.8)

Northeast

36.0

(35.4–36.7)

19.5

(19.0–20.1)

54.2

(53.1–55.3)

South

39.4

(38.9–39.9)

23.0

(22.6–23.4)

58.4

(57.7–59.2)

West

33.2

(32.4–33.9)

15.4

(14.8–16.0)

46.5

(45.1–47.9)

Abbreviations: CVD = cardiovascular disease; CI = confidence interval.

* To meet the U.S. Preventive Services Task Force recommendation eligibility criteria for intensive behavioral counseling for CVD prevention, respondents had to report a body mass index (weight [kg] / height [m]2) of ≥25.0 and one or more of the following CVD risk factors: hypertension, dyslipidemia, or impaired fasting glucose.

To meet the aerobic guideline from the 2008 Physical Activity Guidelines for Americans, respondents had to report engaging in ≥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.

§ Other includes multiracial, Asian, Native Hawaiian or Other Pacific Islander, or American Indian/Alaska Native.

Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.


TABLE 2. Proportion of U.S. adults (N = 408,089) eligible for intensive behavioral counseling for CVD prevention and not meeting aerobic physical activity guideline, by state — Behavioral Risk Factor Surveillance System, United States, 2013

State

Eligible for intensive
behavioral counseling for CVD prevention*

Eligible and not meeting
aerobic physical activity guideline

%

(95% CI)

%

(95% CI)

Total

36.8

(36.5–37.1)

19.9

(19.6–20.1)

Alabama

43.5

(41.7–45.4)

25.6

(24.1–27.1)

Alaska

35.5

(33.4–37.6)

18.0

(16.3–19.8)

Arizona

34.2

(31.6–36.9)

17.6

(15.6–19.8)

Arkansas

42.7

(40.7–44.8)

25.9

(24.2–27.7)

California

33.3

(32.0–34.6)

15.3

(14.3–16.4)

Colorado

30.2

(29.1–31.2)

13.4

(12.6–14.2)

Connecticut

36.8

(35.1–38.5)

20.3

(18.9–21.7)

Delaware

39.6

(37.7–41.5)

21.5

(20.0–23.1)

District of Columbia

30.5

(28.4–32.7)

15.1

(13.6–16.8)

Florida

38.8

(37.5–40.1)

21.3

(20.2–22.5)

Georgia

38.9

(37.4–40.5)

21.7

(20.4–23.0)

Hawaii

29.0

(27.5–30.6)

12.4

(11.3–13.6)

Idaho

35.2

(33.3–37.1)

17.0

(15.5–18.5)

Illinois

34.9

(33.1–36.7)

17.7

(16.4–19.2)

Indiana

38.6

(37.3–39.9)

23.2

(22.1–24.3)

Iowa

36.8

(35.4–38.3)

20.9

(19.7–22.0)

Kansas

35.9

(35.1–36.7)

19.5

(18.9–20.2)

Kentucky

43.0

(41.5–44.5)

24.8

(23.6–26.1)

Louisiana

41.1

(39.0–43.3)

24.3

(22.6–26.2)

Maine

38.9

(37.4–40.3)

20.3

(19.2–21.5)

Maryland

37.9

(36.5–39.3)

21.4

(20.2–22.6)

Massachusetts

33.5

(32.3–34.8)

16.8

(15.8–17.8)

Michigan

40.3

(39.1–41.6)

20.1

(19.1–21.1)

Minnesota

32.4

(30.9–33.9)

16.7

(15.5–18.0)

Mississippi

42.9

(41.1–44.6)

28.8

(27.2–30.4)

Missouri

36.9

(35.2–38.6)

19.2

(18.0–20.6)

Montana

33.6

(32.3–35.0)

16.3

(15.3–17.4)

Nebraska

36.2

(35.0–37.4)

18.5

(17.6–19.5)

Nevada

35.5

(32.9–38.1)

17.7

(15.7–19.8)

New Hampshire

35.5

(33.8–37.1)

17.3

(16.0–18.6)

New Jersey

36.7

(35.3–38.0)

18.7

(17.7–19.8)

New Mexico

33.4

(31.9–34.9)

16.0

(15.0–17.2)

New York

35.4

(34.0–36.8)

20.1

(18.9–21.3)

North Carolina

39.7

(38.2–41.2)

22.1

(20.8–23.3)

North Dakota

34.7

(33.2–36.2)

19.1

(17.9–20.4)

Ohio

37.8

(36.5–39.2)

21.0

(19.9–22.1)

Oklahoma

39.5

(38.1–41.0)

23.7

(22.6–25.0)

Oregon

33.9

(32.2–35.6)

13.8

(12.6–15.1)

Pennsylvania

37.3

(36.0–38.5)

20.6

(19.5–21.6)

Rhode Island

38.8

(37.1–40.5)

21.4

(20.0–22.8)

South Carolina

41.3

(39.9–42.7)

22.6

(21.4–23.8)

South Dakota

36.0

(34.0–38.0)

17.5

(16.0–19.1)

Tennessee

44.6

(42.6–46.7)

28.7

(27.0–30.6)

Texas

36.4

(34.8–38.0)

23.2

(21.8–24.6)

Utah

29.0

(28.0–30.0)

13.9

(13.1–14.7)

Vermont

34.6

(33.0–36.2)

16.5

(15.4–17.8)

Virginia

37.1

(35.6–38.5)

19.5

(18.3–20.7)

Washington

34.0

(32.8–35.3)

15.9

(14.9–16.8)

West Virginia

43.4

(41.9–45.0)

24.8

(23.5–26.2)

Wisconsin

37.0

(35.1–39.1)

18.7

(17.1–20.3)

Wyoming

33.1

(31.4–34.7)

16.3

(15.0–17.6)

Abbreviations: CVD = cardiovascular disease; CI = confidence interval.

* To meet the U.S. Preventive Services Task Force recommendation eligibility criteria for intensive behavioral counseling for CVD prevention, respondents had to report a body mass index (weight [kg] / height [m]2) of ≥25.0 and one or more of the following CVD risk factors: hypertension, dyslipidemia, or impaired fasting glucose.

To meet the aerobic guideline from the 2008 Physical Activity Guidelines for Americans, respondents had to report engaging in ≥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.


FIGURE. Proportion of U.S. adults eligible for intensive behavioral counseling for cardiovascular disease prevention and not meeting the aerobic physical activity guideline,* by state — United States, Behavioral Risk Factor Surveillance System, 2013

The figure above is a map of the United States showing the proportion of U.S. adults eligible for intensive behavioral counseling for cardiovascular disease prevention and not meeting the aerobic physical activity guideline, by state, during 2013.

* To meet the U.S. Preventive Services Task Force recommendation eligibility criteria for intensive behavioral counseling for cardiovascular disease prevention, respondents had to report a body mass index (weight [kg] / height [m]2) of ≥25.0 and one or more of the following risk factors: hypertension, dyslipidemia, or impaired fasting glucose. To meet the aerobic guideline from the 2008 Physical Activity Guidelines for Americans, respondents had to report engaging in ≥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.

Alternate Text: The figure above is a map of the United States showing the proportion of U.S. adults eligible for intensive behavioral counseling for cardiovascular disease prevention and not meeting the aerobic physical activity guideline, by state, during 2013.



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