Objective: The objective of the review was to synthesize the evidence of the effectiveness of lifestyle-based interventions for mitigating absolute cardiovascular disease (CVD) risk. Introduction: Evidence-based guidelines recommend employing an absolute CVD risk score to inform the selection and intensity of preventive interventions. However, studies employing this strategy have reported mixed results, hence the need for a systematic review of the current evidence. Inclusion criteria: Studies published in English that included a lifestyle-based intervention to mitigate CVD risk were considered. Studies were eligible if they enrolled individuals aged ≥18 years, with no history of CVD at baseline. The primary outcome was change in absolute CVD risk score post-intervention. Methods: PubMed, Embase, and CINAHL searches were conducted from database inception to February 2022. The trial registers searched included Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov. Searches for unpublished studies/gray literature were conducted in ProQuest Dissertations and Theses Global, GreyLit Report, and OCLC First Search Proceedings. Two independent reviewers selected the studies and critically appraised them for methodological quality using JBI tools. Data extraction was performed for main outcome variables. Data were presented using separate pooled statistical meta-analysis for quasi-experimental and randomized clinical trials. Random effects models were employed in the analyses. Effect sizes (Cohen’s d) were expressed as standardized mean difference at 95% CI. Heterogeneity was assessed via Cochran’s Q statistic, and the inconsistency index (I ²) was used to describe variability in effect estimates due to heterogeneity rather than sampling error. Results: Twenty-nine studies with a total sample of 5490 adults with no CVD at baseline were included. Fifteen were randomized controlled trials (RCTs; n=3605) and 14 were quasi-experimental studies (n=1885). The studies were conducted in Europe (n=18), the United States (n = 5), Asia (n=3), Mexico (n=1), Canada (n = 1), and Australia (n=1) and included the following lifestyle interventions: diet, physical activity, motivational interviewing, problem-solving, psychological counseling, cardiovascular risk assessment and feedback, health self-management education, and peer support. Six validated absolute CVD risk assessment tools were used to measure the study outcomes, including Framingham, SCORE, Heart Health Risk Assessment Score, Dundee, ASSIGN, and The UK Prospective Diabetes Study risk score. Overall, the methodological rigor of the RCTs and quasi-experimental studies was high. Of the 15 RCTs included in the meta-analysis, lifestyle intervention was favored over control in reducing absolute CVD risk score (Cohen’s d = –0.39; P=0.032; Z= –2.14; I ² = 96). Similarly, in the 14 quasi-experimental studies, the absolute CVD risk score after lifestyle intervention was significantly lower compared to baseline (Cohen’s d = –0.39; P<0.001; Z= –3.54; I ² = 88). RCTs that combined diet and physical activity reported no significant impact on absolute CVD risk score, but those that used either intervention independently reported significant improvement in the absolute CVD risk score. Conclusions: There is evidence supporting the positive impact of lifestyle modification on absolute CVD risk score in adult populations without CVD. Our analysis further suggests that diet and physical activity had significant impact on absolute CVD risk, and a variety of validated screening tools can be used to monitor, evaluate, and communicate changes in absolute risk score after lifestyle modification. Supplemental digital content: A Spanish-language version of the abstract of this review is available [http://links.lww.com/SRX/A29].

Background: Self-monitoring (SM) is the centerpiece of behavioral weight loss treatment, but the efficacy of smartphone-delivered SM feedback (FB) has not been tested in large, long-term, randomized trials. Objective: The aim of this study was to establish the efficacy of providing remote FB to diet, physical activity (PA), and weight SM on improving weight loss outcomes when comparing the SM plus FB (SM+FB) condition to the SM-only condition in a 12-month randomized controlled trial. The study was a single-site, population-based trial that took place in southwestern Pennsylvania, USA, conducted between 2018 and 2021. Participants were smartphone users age ≥18 years, able to engage in moderate PA, with a mean BMI between 27 and 43 kg/m2. Methods: All participants received a 90-minute, one-to-one, in-person behavioral weight loss counseling session addressing behavioral strategies, establishing participants’ dietary and PA goals, and instructing on use of the PA tracker (Fitbit Charge 2), smart scale, and diet SM app. Only SM+FB participants had access to an investigator-developed smartphone app that read SM data, in which an algorithm selected tailored messages sent to the smartphone up to 3 times daily. The SM-only participants did not receive any tailored FB based on SM data. The primary outcome was percent weight change from baseline to 12 months. Secondary outcomes included engagement with digital tools (eg, monthly percentage of FB messages opened and monthly percentage of days adherent to the calorie goal). Results: Participants (N=502) were on average 45.0 (SD 14.4) years old with a mean BMI of 33.7 (SD 4.0) kg/m2. The sample was 79.5% female (n=399/502) and 82.5% White (n=414/502). At 12 months, retention was 78.5% (n=394/502) and similar by group (SM+FB: 202/251, 80.5%; SM: 192/251, 76.5%; P=.28). There was significant percent weight loss from baseline in both groups (SM+FB: –2.12%, 95% CI –3.04% to –1.21%, P<.001; SM: –2.39%, 95% CI –3.32% to –1.47%; P<.001), but no difference between the groups (–0.27%; 95% CI –1.57% to 1.03%; t =–0.41; P=.68). Similarly, 26.3% (66/251) of the SM+FB group and 29.1% (73/251) of the SM group achieved ≥5% weight loss (chi-square value=0.49; P=.49). A 1% increase in FB messages opened was associated with a 0.10 greater percent weight loss at 12 months (b=–0.10; 95% CI –0.13 to –0.07; t =–5.90; P<.001). A 1% increase in FB messages opened was associated with 0.12 greater percentage of days adherent to the calorie goal per month (b=0.12; 95% CI 0.07-0.17; F=22.19; P<.001). Conclusions: There were no significant between-group differences in weight loss; however, the findings suggested that the use of commercially available digital SM tools with or without FB resulted in a clinically significant weight loss in over 25% of participants. Future studies need to test additional strategies that will promote greater engagement with digital tools. Trial Registration: Clinicaltrials.gov NCT03367936; https://clinicaltrials.gov/ct2/show/NCT03367936

The high burden and rising incidence of cardiovascular disease (CVD) in resource constrained countries necessitates implementation of robust and pragmatic primary and secondary prevention strategies. Many current CVD management guidelines recommend absolute cardiovascular (CV) risk assessment as a clinically sound guide to preventive and treatment strategies. Development of non-laboratory based cardiovascular risk assessment algorithms enable absolute risk assessment in resource constrained countries.

Background.Although 80% of the burden of cardiovascular disease (CVD) is in developing countries, the 2010 global burden of disease (GBD) estimates have been cited to support a premise that sub-Saharan Africa (SSA) is exempt from the CVD epidemic sweeping across developing countries. The widely publicized perspective influences research priorities and resource allocation at a time when secular trends indicate a rapid increase in prevalence of CVD in SSA by 2030.Purpose.To explore methodological challenges in estimating trends and burden of CVD in SSA via appraisal of the current CVD statistics and literature.Methods.This review was guided by the Critical review methodology described by Grant and Booth. The review traces the origins and evolution of GBD metrics and then explores the methodological limitations inherent in the current GBD statistics. Articles were included based on their conceptual contribution to the existing body of knowledge on the burden of CVD in SSA.Results/Conclusion.Cognizant of the methodological challenges discussed, we caution against extrapolation of the global burden of CVD statistics in a way that underrates the actual but uncertain impact of CVD in SSA. We conclude by making a case for optimal but cost-effective surveillance and prevention of CVD in SSA.

Background: Metabolic syndrome (MetS) and obstructive sleep apnea (OSA) are associated with increased risk of cardiometabolic disease. The co-occurrence of OSA with MetS is common, but there are limited data on how OSA risk exacerbates the metabolic impairments present in MetS. The purpose of this analysis was to examine in a representative sample of participants in the National Health and Nutrition Examination Survey 2015–2018 cohorts (1) the association of modifiable cardiometabolic risk factors with OSA risk and MetS severity and (2) the influence of OSA risk and lifestyle behaviors on MetS severity. Methods: Metabolic syndrome severity was assessed using MetS Z score, whereas the risk of OSA was measured via multivariable apnea prediction index. Data analyses were conducted using the sample weights provided by the National Health and Nutrition Examination Survey. Results: The sample (N = 11 288) included adults (>20 years old) who were overweight (mean body mass index, 29.6 ± 0.2 kg/m²), representative by race (36.9% non-White) and gender (51.9% female). Overall, 19.3% of the sample had elevated MetS severity (MetS Z score ≥ 1), and 38.4% were at a high risk of OSA (multivariable apnea prediction score of ≥0.50). High OSA risk was associated with having elevated MetS severity (odds ratio [OR], 4.94; 95% confidence interval [CI], 3.68–6.65). Obstructive sleep apnea risk predicted increased MetS severity (adjusted: B = 0.06, SE = 0.02, P = .013). Physical activity provided the highest protection from increased MetS severity (OR, 0.52; 95% CI, 0.39–0.70) and OSA risk (OR, 0.59; 95% CI, 0.53–0.66). Conclusion: Our findings suggest that increased OSA risk exacerbates MetS severity and that greater physical activity may mitigate the risk.