Table 2:

Summary of practical recommendations for service design /delivery and the training of healthcare professionals involved in CVD prevention

Intervention level	Practical recommendations
Pathophysiological	1 Consider baseline BP before initiating intensive BP lowering in combination with intensive glucose lowering.
	2 Consider the established patient CVD risk before deciding on pharmacological intervention.
Individual-level	1 Health promotion pathways should include lifestyle interventions targeting changes in diet, physical activity and weight loss (for those who are overweight or obese) for people with diabetes or non-diabetic hyperglycemia (prediabetes), as well as medication-adherence for those with diabetes. The intensity of interventions should be matched to the level of cardiovascular risk and the risk of T2DM (or its complications).
	2 Maximizing effectiveness of individual level interventions requires the commissioning of both interventions with evidence-based content (see Table 1) and the use of staff with the right competencies and training to effect high quality delivery.
	3 It is worth considering the development of “blended” interventions, where mobile /internet based technologies are used to share information between the patient and the clinician. This can facilitate helpful dialogue and help to facilitate a therapeutic self-management feedback loop including self-monitoring, feedback and individually-tailored problem-solving. eHealth interventions may be effective as stand-alone interventions for some people (those who have the capacity to be pro-active, but should not be relied upon as a whole-population solution.
	4 Although temporary changes in weight /lifestyle can have beneficial longer term effects on blood glucose (particularly in the context of diabetes prevention), greater efforts are required to address the (ongoing) problem of relapse /reversion to prior habits. This may involve the provision of ongoing, regular maintenance contacts beyond the initial intervention period.
Population-level	1 The workplace setting is a highly attractive environment for population-level interventions as it incorporates social support in a stable environment.
	2 There is a strong need for programs and trials providing longitudinal and more definitive data on the impact of population-level interventions on cardiometabolic risk factors and diseases.
General recommendations on competencies for training and standardizing health promotion care pathways	1 Integration of existing CVD prevention and diabetes prevention, or diabetes self-management programs have the potential to improve care pathways.
	2 Task-shifting in multidisciplinary care teams, especially involving community pharmacist and/or nurses, may improve clinical outcomes and may be of special benefit in regions where shortage of service limits availability of care.
	3 CVD prevention service provider staff need to have /be trained to have the following competencies: Delivery of group or individual level behavior change interventions including: Facilitation of key behavior change techniques, including motivation-building using personcentered counselling techniques, making action plans, supporting self-monitoring (including the use of digital and blended care approaches), facilitating barrier identification and problem-solving and identifying and addressing social influences.
	4 CVD prevention service managers need to have /be trained to have the following competencies …. Understanding the evidence (as presented here) and being competent in commissioning /co-design of effective, evidence-based behavior change programs and training courses that will deliver the above competencies. Making the case to policy makers to acquire sufficient funding to deliver effective lifestyle interventions. Cutting corners when translating clinical intervention programs into real-world settings is likely to undermine effectiveness and cost-effectiveness (148). Designing stepped care pathways to ensure that the type / intensity of intervention is mapped to individual needs and capabilities.

Left column shows the focus of the individual review sections (pathophysiological and lifestyle interventions targeting the individual and the population); right column shows practical recommendations derived from the evidence identified in each section; last row synthesizes the evidence into general recommendations on competencies for training and standardizing health promotion care pathways for the individual sections

BP = Blood pressure; CVD = Cardiovascular disease; T2DM = Type 2 diabetes mellitus; eHealth = electronic health