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Effects of Partners Together in Health Intervention on Physical Activity and Healthy Eating Behaviors: A Pilot Study

Yates, Bernice C. PhD, RN; Norman, Joseph PhD, PT; Meza, Jane PhD; Krogstrand, Kaye Stanek PhD, RD; Harrington, Susana APRN; Shurmur, Scott MD; Johnson, Matthew MD; Schumacher, Karen PhD, RN

The Journal of Cardiovascular Nursing: March/April 2015 - Volume 30 - Issue 2 - p 109–120
doi: 10.1097/JCN.0000000000000127
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Background: Despite proven efficacy of cardiac rehabilitation (CR) in helping patients initiate physical activity and healthy eating changes, less than 50% of CR participants maintain changes 6 months later.

Objective: The objective of this feasibility study was to test the Partners Together in Health (PaTH) intervention versus usual care in improving physical activity and healthy eating behaviors in coronary artery bypass graft surgery patients and their spouses.

Methods: An experimental, 2-group (n = 17 couples/group), repeated-measures design was used. Coronary artery bypass surgery patients in both groups participated in phase II outpatient CR. Spouses in the PaTH group attended CR with the patient and were asked to make the same physical activity and healthy eating changes as patients did. Spouses in the usual care attended educational classes with patients. It was theorized that “2 persons would be better than 1” at making changes and sticking with them in the long-term. Physical activity behavior was measured using the Actiheart accelerometer; the activity biomarker was an exercise tolerance test. Eating behavior was measured using 3-day food records; the biomarker was the lipid profile. Data were collected at baseline (entrance in CR), at 3 months (post-CR), and at 6 months. Changes over time were examined using Mann-Whitney U statistics and effect sizes.

Results: The PaTH intervention was successful primarily in demonstrating improved trends in healthy eating behavior for patients and spouses. No differences were found between the PaTH and usual care patients or spouses at 3 or 6 months in the number of minutes per week of physical activity. By 6 months, patients in both groups were, on average, below the national guidelines for PA recommendations (≥150 min/wk at >3 metabolic equivalents).

Conclusions: The couple-focused PaTH intervention demonstrated promise in offsetting the decline in dietary adherence typically seen 6 months after CR.

Bernice C. Yates, PhD, RN Professor, College of Nursing, University of Nebraska Medical Center, Omaha.

Joseph Norman, PhD, PT Professor and Program Director of Physical Therapy, School of Allied Health Professions, University of Nebraska Medical Center, Omaha.

Jane Meza, PhD Professor, College of Public Health, University of Nebraska Medical Center, Omaha.

Kaye Stanek Krogstrand, PhD, RD Emeritus Associate Professor, Department of Nutrition and Health Sciences, University of Nebraska, Lincoln.

Susana Harrington, APRN Cardiothoracic Surgery Nurse Practitioner, Nebraska Methodist Hospital, Omaha.

Scott Shurmur, MD Associate Professor, Internal Medicine Division of Cardiology, College of Medicine, University of Nebraska Medical Center, Omaha.

Matthew Johnson, MD Cardiologist, Bryan LGH Heart Institute, Lincoln, Nebraska.

Karen Schumacher, PhD, RN Associate Professor, College of Nursing, University of Nebraska Medical Center, Omaha.

This research was supported by grant R15 NR010923 from the National Institute of Nursing Research (NINR), National Institute of Health (NIH), and by the University of Nebraska Medical Center Clinical Research Center, Research Support Fund, and by Grant P20 NR011404 from NINR, NIH.

The authors have no conflicts of interest to disclose.

Correspondence Bernice C. Yates, PhD, RN, 985330 Nebraska Medical Center, Omaha, NE 68198-5330 (bcyates@unmc.edu).

Coronary heart disease (CHD) remains the leading cause of morbidity and mortality in the United States for both men and women. The most recent statistics from the American Heart Association reported that there were more than 785 000 new myocardial infarctions each year in the United States and more than 232 000 coronary artery bypass graft (CABG) surgeries.1 There are several modifiable risk factors for heart disease, including smoking, sedentary lifestyle, high-fat diet, and hyperlipidemia to name a few.1,2

Long-term maintenance of lifestyle changes to reduce cardiovascular risk factors for patients after CABG surgery is essential to fully reap the benefits of the CABG surgery. Despite proven efficacy of cardiac rehabilitation (CR) in helping patients initiate lifestyle changes, less than 50% of CABG patients maintain these changes by 6 months after CABG.3–5 In addition, spouses of CABG patients often share the same lifestyle as the patient’s (ie, lack of activity, high fat diet, etc) and may also have an elevated risk profile.6,7 Cardiac rehabilitation is an excellent opportunity to combine strategies of secondary prevention for patients with strategies of primary prevention for spouses by involving them in the patients’ outpatient CR efforts. Unfortunately, most of the existing couple-oriented interventions involve the spouse as a way to improve patient adherence to medical guidelines6,7 or to address the role of marital functioning in illness management,8,9 with limited opportunity for health promotion for the spouse.6–8 Lifestyle interventions that specifically target the marital partners as a unit may be more efficacious than current individually oriented education strategies. The purpose of this study was to examine the differences between patients and spouses in 2 groups (Partners Together in Health [PaTH] intervention vs. usual care [UC]) in changes over time in physical activity (PA) behavior and PA biomarker (functional capacity) and in healthy eating behaviors and biomarkers (lipid profile).

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Background

Research has focused on achievement of target PA/exercise goals within CR programs. Several investigators have found significant improvements in functional capacity during CR,10–13 ranging from 23%10 to 36%.11 Although exercise performance increases in CR, there is a downward trend for PA/exercise participation during the year after CR.14–16 Moore et al15 found that 1 year after a cardiac event, only 28% of patients in a lifestyle exercise intervention met the minimum weekly guideline of 150 min/week17 of moderate PA.

Heart-healthy dietary changes in patients with CHD have been found to lower blood pressure (BP) and reduce the risk of CHD, myocardial infarction, and stroke.18–22 However, adherence to dietary recommendations is less than desirable among patients with CHD.23,24 Although most patients followed a heart-healthy diet during CR, less than half of the participants were following the diet 1 to 3 years later.24 In the OASIS (Organization to Assess Strategies in Acute Ischemic Syndromes) trial, 21% of participants did not adhere to diet or exercise prescriptions, 43% adhered to 1 or the other, and 36% adhered to both diet and exercise at 3 months after event.20 In a recent meta-analysis of the effects of diet, exercise, or both diet and exercise on lipids, reductions in serum cholesterol and low-density lipoprotein cholesterol (LDL-C) levels were greater for diet and diet and exercise combined.25 In contrast, reductions in triglycerides were limited to the effects of exercise.25 More studies are needed examining intervention strategies that improve dietary and lipid changes after CABG surgery.

Few studies have been carried out examining the risk factors and/or health behaviors of the healthy spouse of patients with CHD. In a descriptive study, CHD patients’ and spouses’ lifestyle behaviors were significantly correlated in relation to shared high-fat diet, sedentary lifestyle, overweight, and smoking behavior, placing the spouse at risk for CHD.26 In 1 of the few intervention studies, Mosca et al27 provided risk factor screening and lifestyle counseling (primary prevention) for family members of patients undergoing cardiac revascularization, 65% of whom were spouses (Family Intervention Trial for Heart Health). Compared with control group participants, those in the intervention group demonstrated a greater likelihood to exercise more than 3 days per week,27 better adherence to the therapeutic lifestyle change (TLC) diet, and improved high-density lipoprotein (HDL) levels.28 Contrary to expectations, LDL-C level decreased in both groups, with no significant difference between groups. In other studies, partners of cardiac patients also demonstrated improved dietary outcomes in response to family-based cardiovascular prevention programs.29,30 Thus, there is preliminary evidence that a risk reduction program may benefit the healthy spouse, although no studies were found using CR for this.

Family- or couple-focused interventions in cardiovascular disease are in their early stages. Dunbar et al31 tested a family partnership intervention and found that involving the partner in sessions on family support and patient choice helped improve the heart failure (HF) patient’s dietary sodium self-management. Stewart et al,32 testing a 12-week support group intervention, found that participants reported improved relations with spouse, enhanced coping, increased confidence about lifestyle change, and changed outlook. A recent meta-analysis examined 25 randomized couple-centered interventions in chronically ill patients and their partners, 7 of which were cardiac trials.8 They found that couple interventions were successful in reducing patients’ depressive symptoms, enhancing marital functioning, and reducing pain.8 In contrast, 2 studies did not find significant improvements on indicators of family functioning and family resources.33,34 Mosca et al27 described family involvement as a motivational moment that should be used to promote health/reduce cardiovascular risk factors in healthy family members who may share poor lifestyle behaviors or the genetics of the patient with CHD.

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Conceptual Basis

The PaTH intervention was guided by theoretical concepts from social cognitive theory35 and social support theory.36 Cardiac rehabilitation is designed to build self-efficacy through 4 main sources: successful performance of a behavior (losing weight), vicarious experiences (learning by observing role models), persuasion by authority (healthcare professionals), and physiological feedback (interpret symptoms accurately).35 Social support, delivered within the PaTH intervention, is theorized to function through 3 support dimensions: emotional, tangible, and informational support.36 First, emotional support (expressions of caring, empathy, and acceptance) functions to reduce the appraised threat of the cardiac event and to reassure one another that they are loved and accepted in this new set of circumstances. Tangible aid is important, particularly in early phases of CR, to assist individuals with tasks that they temporarily need assistance with (cooking, transportation). By exercising in CR and following the cardiac diet together, the 2 members of the dyad provide practical assistance for each other for adopting health-promoting behaviors. Third, informational support includes advice and suggestions about what to do, how to solve problems, or where to get needed information (from each other, CR staff). If the couple builds new habits together, they can motivate and support one another to engage in these behaviors and continue with them in the long-term. These lifestyle changes may, in turn, improve the cardiovascular health of both individuals. Although the spouse was included in the above-cited studies, few studies measured their outcomes in response to an intervention and no studies were found that included the spouse in an existing CR program to make the same lifestyle changes as the patient as in this study.

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Methods

Design

This pilot study used an experimental, 2-group, repeated-measures design to examine differences between the PaTH intervention group and the UC group in patients’ and spouses’ PA and healthy eating behaviors in response to CR.

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Setting and Target Population

A convenience sample from a mid-Western academic medical center and a community hospital was used. This study (referred to as the PaTH intervention study) was a feasibility trial to pilot test the effects of the PaTH intervention versus UC in improving PA and healthy eating behaviors, quality of life, and risk factors for heart disease. Spousal caregivers in the PaTH intervention group joined CR with the patient to participate in exercise sessions and educational classes to undertake comprehensive risk reduction for themselves; caregivers in the UC group were invited to attend the educational sessions with the patient.

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Eligibility Criteria

Eligibility criteria include the following: (a) 19 years or older (age of most in Nebraska), (b) diagnosis of CABG surgery and enrollment in outpatient CR, (c) married or living with partner for more than 1 year, (d) partner was also willing to participate, (e) no history of psychiatric illness, and (f) classified as low to moderate risk for the occurrence of cardiac events during exercise.37 Eligibility criteria for spouses include the following: (a) 19 years or older, (b) no history of psychiatric illness, (c) classified as low to moderate risk for the occurrence of cardiac events during exercise, (d) married or living with the CABG surgery patient for more than 1 year, and (e) written permission from the primary healthcare provider to participate in the study. Exclusion criteria for both patients and spouses were (a) orthopedic problems that would prevent them from walking on a treadmill to maximum effort; (b) history of cardiac arrest, sudden death, or complex dysrhythmias at rest; (c) resting systolic BP greater than 200 mm Hg or diastolic BP greater than 100 mm Hg; (d) debilitating noncardiac disease such as renal failure or anemia, severe chronic obstructive lung disease, or poorly controlled diabetics (diagnosed with diabetic ketoacidosis within the past 6 months or a current hemoglobin A1c level >11); and (e) diagnosis of HF with an ejection fraction less than 35 and/or clinical evidence of decompensated HF.37

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Sample

Approximately 158 couples were assessed for eligibility (Figure). We excluded 86 couples because they did not meet inclusion criteria, leaving 72 eligible couples. Another 33 declined to participate. Thus, the participation rate was 54% (39 consented/72 eligible participants). Of the 39 couples who were eligible and consented to be in the study, we were unable to schedule 4 couples for baseline data collection. Therefore, 35 couples were randomly assigned to either the PaTH group (n = 18) or the UC group (n = 17). One patient in the PaTH group did not tolerate the baseline exercise test because of orthopedic problems and the couple was withdrawn from the study, yielding an attrition rate of 12.8% (5/39). Consequently, the final sample consisted of 17 couples in each group. One patient in the UC group dropped out of the CR early (completed 33% of the CR program, 12/36 planned exercise sessions) but finished the remainder of the study protocol. No couples in either group were lost to follow-up; however, 1 patient in the UC group worked out of town, so follow-up data were incomplete. Because men comprise most (65%–70%) of CABG surgery patients,38 randomization was stratified by clinical sites and patient gender so that a 70% male to 30% female proportion of patients was randomized to the 2 groups. Couples were randomly assigned, in blocks of 4 or 6, to either the PaTH or UC group using a statistician-generated randomization schedule. This study included 34 CABG surgery patients and their spouses/partners. Because this study was considered a feasibility study, with results being used to guide further research, the final sample size was determined by logistical and budgetary constraints.

FIGURE

FIGURE

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Intervention

Patients in both groups and partners in the PaTH intervention group began outpatient CR within 3 to 5 days at the community hospital and within 2 to 3 weeks at the academic medical center after hospital discharge. Both CR programs are nationally certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (https://www.aacvpr.org/Certification/CertificationCenter/tabid/496/Default.aspx), indicating standardized program elements. Individualized counseling and education were provided by a multidisciplinary team of nurses, dietitians, pharmacists, exercise specialists, and physicians. Individualized exercise plans were implemented that included aerobic, strength, and flexibility exercises, 3 days a week for 6 to 12 weeks (18–36 sessions). Although it was preferred to standardize the number of exercises sessions, these were ultimately dependent upon the patients’ insurance coverage because of the fiscal constraints of the grant. Group education classes in nutrition, exercise, smoking cessation, knowledge of heart disease and risk factors, stress management, medications, and lifestyle change were offered on a regular cycle.

Patients in both CR groups were provided with individualized counseling, education, and goal setting in relation to lifestyle changes (ie, exercise regularly, eat low-fat diet, lose weight, etc) and feedback about progress toward goals at regular intervals. Spouses in the PaTH intervention group were also provided with these same CR features. Spouses in the UC group were invited to participate in the group educational sessions. The CR program at the community hospital had an established program that allowed partners to exercise in the facility. Thus, although these spouses all chose to exercise with their mate in CR, these spouses did not receive individual counseling, monitoring, goal setting, and regular reassessments and feedback.

The specific diet goals that were negotiated with CR participants as part of the TLC diet were the following: 25% to 35% of total calories as fat, less than 7% as saturated fats, less than 200 mg/d of cholesterol, and 10 to 25 g/d of soluble fiber.39,40 The goal for lipid management in the secondary prevention of CHD is to reduce the LDL-C to less than 70 mg/dL.40 The goal for lipid management in primary prevention of CHD is to reduce the LDL-C to less than 130 mg/dL if no risk factors and to less than 100 mg/dL if 2 or more risk factors.39,40 The specific PA goals that are negotiated with CR participants are based on the American Heart Association’s and the American College of Sports Medicine’s position stands on exercise, which recommend that individuals participate in at least 30 minutes of continuous or accumulated moderate PA on most or preferably all days of the week (minimum goal is ≥150 min/wk at ≥3.0 metabolic equivalents [METs]).17 Moderate-intensity PA generally requires sustained rhythmic movements and refers to effort expended while walking briskly, mowing the lawn, dancing, swimming, or bicycling.

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Measures

The primary outcome variables that were measured in this study were PA/exercise and dietary intake behaviors and biomarkers. These behaviors were chosen because they are the risk-reducing behaviors that are relevant to all individuals (patients and spouses) and they were the targeted behaviors that all CR patients and PaTH spouses were requested to change. Patients and spouses in both groups completed all of the measures at the 3 time points: baseline (close to the start of CR), post-CR (3 months), and at 6 months. In all of the measures, we calculated change scores to examine improvement over time between baseline and 3 months and between the 3- and 6-month data collection points.

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Physical Activity Behavior

Physical activity was measured objectively by the Actiheart monitor (CamNTech Company, United Kingdom; www.camntech.com/products/actiheart/actiheart-overview). The Actiheart was worn on 2 standard electrocardiogram (ECG) pads on the chest for 7 days at each data collection point. The Actiheart simultaneously records activity and heart rate (HR) and uses both parameters to calculate physical activity energy expenditure. By combining both activity and HR, the accuracy of the energy expenditure calculation is substantially improved over using just activity or HR alone. Energy expenditure calculations are within 0.02 kJ/kg/min of those measured by a Cosmed K4b23 (Cosmed USA, Inc, Concord, CA, http://www.cosmed.com), indicating strong accuracy.41 Physical activity energy expenditure estimates were compiled for all participants with at least 4 valid days of wear time. Physical activity energy expenditure estimates were calculated using summed daily minutes of time spent in activities that were 3.0 METs or higher because 3.0 METs is the starting MET level for moderate-intensity PA (MET = metabolic equivalent of task is a physiological measure expressing the energy cost of physical activities).42 Time spent in PA of 3.0 METs or greater was summed across the days, divided by the number of days for an average daily level of PA, and then multiplied by 7 for an average weekly level of PA.

The biomarker of PA/exercise was functional capacity assessed from an exercise tolerance test (ETT). The ETT was not a diagnostic test but rather a test of participants’ functional capacity from which to ensure they were safe to exercise and measure change and improvement over time.43 A conservative ramp protocol was used where speed and grade increased gradually every 30 seconds.44 Participants began by sitting quietly at rest for 5 minutes to allow for monitoring and recording of baseline HR, BP, and cardiac rhythm. During the test, participants were monitored continuously with a 12-lead ECG. Auscultatory BP readings and the Borg 6–20 scale for Rating of Perceived Exertion were obtained every 2 minutes during the test. The length of the ETT was limited to 10 minutes to ensure that individuals reached their maximum effort (termination criteria below) rather than quit early because of fatigue. Thus, the starting MET level for each participant differed and accounted for their current levels of PA and physical functioning. The tests were supervised by a cardiology fellow at the medical center and by an advanced practice nurse at the community hospital, who were blinded to the participant’s group status. The primary investigator was also present at each ETT and was blinded to group assignment to ensure consistent testing between the 2 clinical sites. Termination criteria for the test were (1) subject request, (2) symptoms (fatigue, shortness of breath, angina, claudication, or other signs and symptoms of exercise intolerance), (3) the development of abnormal ECG changes suggestive of ischemia or significant arrhythmia, and (4) a drop in systolic BP (≥20 mm Hg) or an abnormal rise in diastolic BP (≥20 mm Hg over baseline). After peak effort was reached, participants walked on the treadmill at a slow pace for 5 minutes before sitting on a chair for the remainder of recovery. During recovery, HR, BP, and cardiac rhythm were monitored for 10 to 15 minutes. The maximum MET level achieved on the ETT was the variable used in the analysis.

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Dietary Intake Behavior

The 3-day food record was used to assess food intake and changes in eating behavior over time.45 This technique is a well-accepted measure of dietary intake.46,47 The participant recorded all food and beverages consumed on 3 typical days including 2 weekdays and 1 weekend day. The participants were asked to describe in as much detail as possible their food intake, recording ingredients, name brands, and portion sizes. Portion sizes were estimated based on standard household measures and the use of a packet of food pictures depicting portion sizes provided to each participant. The participants were instructed in the method of completing the 3-day food record by a member of the research team. Dietary intake data were then entered and analyzed using the Nutrition Data System for Research (NDS-R) software48 by a dietitian who was blinded to group assignment. The NDS-R software provides a complete nutrient profile for all foods in the database. The NDS-R has a comprehensive quality control system to ensure the accuracy and internal consistency of the database.49 Using this software, the following variables were generated for analysis based on a 3-day average intake: (1) cholesterol intake (milligrams per day), (2) percentage of fat calories in diet, (3) percentage of saturated fat calories in the diet, and (4) fiber (grams per day).

A lipid profile was also measured as a biomarker of eating behavior to examine the effects of modifications in dietary behaviors. Baseline lipid profiles were drawn before the start of CR in spouses. The preferred time to draw lipids in patients is before surgery because lipid values are not accurate until 6 weeks after CABG surgery. Thus, we used preoperative lipids as the baseline values for patients whose preoperative lipids were available (80%). In the remaining patients, lipids were drawn 6 weeks after surgery, when it had returned to presurgery values. This did not differ across groups. Both patients and spouses also had them drawn at 3 and 6 months after CABG surgery to examine changes in lipid profile. The profile includes measurements of total cholesterol, HDL cholesterol, LDL-C, and triglycerides. Participants were instructed to fast for 12 hours and avoid alcohol consumption for 24 hours before having their blood drawn. The method, used by all laboratories, met the Laboratory Standardization Panel recommendation of bias 3% or less.

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Procedures

Participants were mailed the study questionnaires 7 to 10 days ahead of their in-person visit for their ETT and were instructed to complete these before the ETT. At the time of the face-to-face visit and ETT, the questionnaires were reviewed by project staff for any missing data. The 3-day food records also were reviewed closely for completeness.

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Data Analysis

Analysis of PA and eating behavior outcomes was done to test whether significant differences were found between the PaTH group and UC group at the end of CR (3 months) and at follow-up (6 months). Two change scores were calculated: Change between baseline and 3 months was calculated by subtracting baseline from 3-month scores, and change between 3 and 6 months was calculated by subtracting 3-month from 6-month scores. The 3- and 6-month change scores were compared between the intervention and usual care groups using a Mann-Whitney test. The level of significance for all comparisons was set at P < .05 (2-tailed tests). However, because this was a feasibility study and we were interested in calculating effect sizes (ESs) from the data, the following values were used for interpreting ES using the Mann-Whitney test: small, 0.10; medium, 0.30; large, 0.50, equivalent to Cohen f values of 0.10, 0.25, and 0.40, respectively.50 Analysis was conducted on an intent-to-treat basis. Patients were analyzed according to their randomized assignment. There was a very small amount of missing data; thus, analyses were performed on the variables with complete data only.

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Results

Table 1 contains the demographic and illness characteristics of the sample by group. On average, most of the couples were married, white, and employed and had a high school education and an annual household income between $30 000 and $70 000. In relation to CR, patients in both groups demonstrated very good adherence to both the exercise (≥90%) and educational (>75%) sessions. Spouses in the PaTH group also demonstrated very good adherence to the exercise sessions (89%). Adherence to the educational sessions was lower for PaTH (79%) and UC (68%) spouses compared with patients. Most UC spouses at the community hospital site also participated in the exercise sessions (94%), although they did not receive the individual counseling, monitoring, goal setting, and regular reassessments and feedback. In relation to illness characteristics, patients had similar numbers of bypass grafts and ejection fraction and most patients were on lipid medications. In contrast, less than half of the spouses in both groups were on lipid medication. There were no differences between patient groups or between spouse groups in demographic and CR characteristics.

TABLE 1

TABLE 1

The results can be found in Tables 2 (patients) and 3 (spouses). Patients in both groups increased their PA levels between the start and end of CR (favored UC group, ES = 0.14). In contrast, between the end of CR (3 months) and at 6 months, PA levels declined in both groups. The median levels of PA at 6 months were below the recommended guidelines of moderate-intensity PA (≥150 min/wk). Functional capacity increased in both groups between baseline and 3 months (favored UC group, 0.11) and between 3 and 6 months (favored PaTH group, ES = 0.29). Similarly, between the start and end of CR, eating behavior improved more for patients in the UC group than for those in the PaTH group (less dietary cholesterol, percentage saturated fat calories, and more fiber intake); but by 6 months, this trend reversed, and now the PaTH group, exhibited better eating behaviors in relation to lower percentage of saturated fat calories.

TABLE 2

TABLE 2

TABLE 3

TABLE 3

In relation to the patients’ lipid results, the UC care group experienced more decline in serum cholesterol and LDL-C between baseline and 3 months (ES = 0.12 and 0.16, respectively). Between 3 and 6 months, serum cholesterol increased in both groups but the PaTH group experienced a smaller increase than the UC group (ES = 0.15). High-density lipoprotein did not change between baseline and 3 months in either group but significantly increased in the UC group between 3 and 6 months (P = 0.01; ES = 0.47). Triglycerides were stable over time in both groups.

Spouses in both groups demonstrated similar increases in PA behavior between baseline and 3 months as patients and declines between 3 and 6 months. At both 3 and 6 months, the median levels of PA for spouses in both groups were above the recommended guidelines per week of moderate-intensity PA (≥150 min/wk). Eating behavior improved more for spouses in the UC group between baseline and 3 months (dietary cholesterol and fiber intake) (small ES) and improved more for spouses in the PaTH group between 3 and 6 months (percentage fat and saturated calories and cholesterol) (small–medium ES). Lipid results mirrored the trends in eating behavior showing improvement in the UC group between baseline and 3 months and improvement in the PaTH group between 3 and 6 months. The 1 exception was that the UC group improved HDL (ES = 0.25) between 3 and 6 months.

Across all 10 indicators, 7 indicators favored the UC group and 3 were equal between patient groups at the end of CR. However, at 6 months, there was an opposite trend, where 2 indicators favored the PaTH group, 4 were equal between groups, and only 4 favored the UC group. In spouses, 5 indicators favored the UC group, 2 favored the PaTH group, and 3 were equal between groups at the end of CR. In contrast, at the 6-month follow-up, 6 indicators favored the PaTH group, 3 were equal between groups, and only 1 favored the UC group.

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Discussion

The PaTH intervention was successful primarily in demonstrating improved trends in healthy eating behavior for patients and spouses. The improved eating behavior of the couples was likely facilitated by the unique couple-focused intervention in that couples were asked to work together to build new eating habits. The other main finding of the PaTH intervention was that patients and spouses continued to report improvements between 3 and 6 months, which is typically when adherence starts declining in CR programs.21 Thus, the PaTH intervention was successful in offsetting decreasing adherence. Another unique aspect of this study is that few previous studies measured outcomes in spouses.8 In their meta-analysis, Martire et al8 found that only 2 of the 7 couple-oriented studies involving CHD patient-partner dyads reported partners’ outcomes, thus limiting our understanding of how CABG surgery impacts both members of the patient-spouse dyad. However, the findings from this pilot study warrant testing in a larger sample size to determine whether the couple-focused intervention is more effective for additional PA and risk factor outcomes than current individually oriented education strategies.

The PaTH intervention was not successful in bringing about lasting outcomes in PA behavior in patients and spouses. Although PA levels increased in patients and spouses in both groups during CR, these decreased after CR. It is likely that the lack of differences between the UC and PaTH groups was because of the clinical site that allowed partners to exercise with patients. This was also primary recruitment site, so it was likely that partner participation at this site attenuated the effects of the PaTH intervention. In a recent study, Ferrier et al51 found that the behavioral intervention strategies that were successful in increasing patients’ PA after CR were self-monitoring, specific goal setting, identifying barriers, and plans for relapse prevention. These strategies, in addition to a true control group, need to be built into a future study testing the PaTH intervention in a larger sample.

At 6 months, patients in both groups were engaged in less than 150 min/wk of moderate-intensity PA, the level sufficient to lower risk of CHD.17 These findings are supported by previous studies. Moore et al15 also found that many participants in a lifestyle modification program designed to maintain PA levels after CR were exercising below the recommended levels. In the current study, spouses met the recommended guideline (≥150 min/wk) of moderate-intensity PA and were almost twice as active as patients at all 3 time points.

The PaTH intervention was successful primarily in demonstrating improved trends in dietary intake for patients and spouses. These results were supported by findings from 2 previous studies in which dietary outcomes were better for the family-based intervention group compared with the control group.27,30 In this study, the spouse was the primary person preparing the family meals in both groups. Spouses in the PaTH group may have worked harder to follow the TLC diet than spouses in the UC group because the PaTH participants had been asked to work together as a couple to follow the dietary guidelines and thus were more committed to cooking and adhering to the TLC diet.

Based on the results of this study, the couple-oriented focus of the intervention needs to be enhanced in a future study. Although CR programs invite the spouse or family to attend the educational classes, they typically have an individual focus. That is, content is directed at the patient with the expectation that the spouse will help the patient adhere to the healthcare recommendations. In addition, the couple may not have the best ways of interacting or may not understand how to support one another. Thus, couples need to be taught how to work together to make these lifestyle changes. In a future study, the PaTH intervention needs to be more robust to include sessions about how best to support one another when making lifestyle changes, what changes can be expected in family relationships in response to a life-threatening illness and how these affect illness management, and skills training in clarifying expectations for PA/exercise and healthy eating changes.

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Limitations

There were several limitations in this study. Because this was a feasibility study, the study was underpowered to detect statistically significant differences, and the results must be interpreted with caution. Although trends were in the right direction and favored the PaTH intervention group, particularly at 6 months, a larger sample size and a longer follow-up period are needed to more definitively test the effects of the PaTH intervention versus UC in improving PA and healthy eating behaviors and their respective biomarkers for patients and spouses after CABG surgery. Another limitation was that the UC group differed for spouses between the 2 clinical sites. Spouses in the UC group at the community hospital were able to exercise with patients although they did not receive individualized risk factor counseling, exercise prescription updates, or monitoring. This variation on the planned UC intervention may have impacted outcomes, and it is likely that we would have seen even greater effects of the PaTH intervention for spouses with a true control group. In a larger study, spouses who elect to enroll in the partnership program will not be allowed to participate in the study. There was also limited racial/ethnic diversity in the sample; however, the sample was representative of the racial diversity in the metropolitan area where the study was conducted. In addition, selection bias may have been operating in that it was a convenience sample and we may have attracted couples to the study who were interested in working together as a couple. Thus, those couples whose marital satisfaction was lower may not have chosen to participate in the study.

In summary, the PaTH intervention demonstrated promising results for facilitating positive PA and healthy eating behaviors in patients and spouses after CABG surgery as a couple-focused intervention. A larger sample and a longer follow-up period are needed to definitively test the impact of the PaTH intervention on patients and spouses in a future study. In a larger study, it is hypothesized that the PaTH intervention, where 2 people work together to make lifestyle changes and support one another, will yield better adherence to PA and dietary guidelines and promote cardiovascular health for both patient and partner than will individually focused (patient only) interventions that are currently in use.

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What’s New and Important

  • A couple-focused intervention, PaTH, demonstrated promise in offsetting the decline in dietary adherence typically seen 6 months after CABG surgery.
  • Patients and spouses in the PaTH intervention group continued to make positive lifestyle changes after completing CR compared with patients and spouses in the UC group.
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Acknowledgments

The authors acknowledge the assistance and support from Dr John Batter at the Nebraska Methodist Hospital, the CR staff at the Nebraska Methodist Hospital and the Nebraska Medical Center, the Cardiology Fellows at the Nebraska Medical Center, Roxanne Cox for her invaluable literature searches, and to the Graduate Research Assistants: Karin Ashley, Esther Park, Crystal Epstein, and Jennifer Schmitz.

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REFERENCES

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Keywords:

cardiac rehabilitation; couples; diet; physical activity

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