The treatment of coronary heart disease (CHD) has evolved from simple lifestyle modifications, largely focused on early ambulation, exercise training, and a prudent diet, to an array of costly and palliative coronary revascularization procedures that fail to address the foundational or most proximal risk factors (RFs) for CHD, including physical inactivity, poor dietary habits, and cigarette smoking. However, contemporary studies now suggest that behavior change and multifactorial RF modification—especially smoking cessation and more intensive measures to control hyperlipidemia with diet, drugs, and exercise—may slow, halt, or even reverse (albeit modestly) the otherwise inexorable progression of atherosclerotic CHD.1 Prevention can be divided into 3 types: primordial (prevention of RFs); primary (treatment of RFs); and secondary (prevention of recurrent cardiovascular [CV] events), which can be modulated by lifestyle modifications and cardioprotective medications, when appropriate (Figure).2,3 This commentary builds on the above-referenced themes, with specific reference to unhealthy lifestyle habits, population health, RFs as harbingers of CV disease (CVD), current provider counseling practices, assessing patient readiness to change, and research-based interventions to facilitate behavior change (eg, the 5A's, motivational interviewing, and overcoming inertia with downscaled goals). Beyond the counseling skills of highly trained professionals (eg, psychiatrists, psychologists, and social workers), this review highlights the need for and potential impact on lifestyle modifications that nonbehavioral scientists, specifically physicians and allied health professionals, can have on the patients they serve.
UNHEALTHY LIFESTYLE HABITS, POPULATION HEALTH, AND MORTALITY
Population health is largely modulated by 5 domains: genetic predisposition; social circumstances; environmental exposures; behavioral patterns; and, access to quality health care. However, the single greatest opportunity to improve health and reduce premature death lies in favorably modifying unhealthy behaviors, which account for ∼40% of all deaths in the United States.4 The top 2 behavioral causes of premature death, cigarette smoking and obesity/physical inactivity,5 a result of technologic advances as well as unhealthy dietary and lifestyle choices, are most prevalent among those with low socioeconomic status.4 Because patients with chronic disease typically spend only a few hr/yr with a doctor or a nurse,6 it is critical to connect them with health-promoting resources in their immediate environment, including university-based healthy lifestyle programs, worksite wellness initiatives,7 community resources,8 and prevention-focused health care systems.9
The Behavior Risk Factor Surveillance System reported that only 3% of 153 805 US adults adhere to 4 healthy lifestyle characteristics, including the avoidance of cigarette smoking, maintaining a normal body mass index (BMI; 18.5-24.9 kg/m2), consuming ≥5 servings/d of fruits and vegetables, and regular moderate-to-vigorous (>150 min/wk) physical activity (PA).10 Relative to secondary prevention, a substantial percentage of patients undergoing elective percutaneous coronary intervention (PCI) for stable angina do not achieve lifestyle and RF goals and therefore remain at increased risk for recurrent cardiac events.11 At 13 mo after PCI, only 46% of the patients were exercising regularly, 13% had received dietary counseling, and just 8% of the smokers had quit. Moreover, 75% of the patients that were overweight or obese at baseline had comparable BMI at follow-up.
To evaluate the prevalence of healthy lifestyles (ie, no smoking, healthy diet, and regular PA) among individuals with self-reported CVD, researchers studied 7519 patients (age 57.2 ± 9.0 yr, 47% male) with a previous cardiac or stroke event in high-, middle-, and low-income countries.12 Approximately, 4.5 yr after their acute CV event, 18% continued to smoke, only 35% undertook high levels of leisure-time PA, and 39% had healthy diets. Interestingly, 14% of the patients reported none of the 3 healthy lifestyle behaviors. In addition, only 43%, 31%, and 4% had 1, 2, or all 3 healthy lifestyle behaviors, respectively. The prevalence of healthy lifestyle behaviors was surprisingly low, with even lower levels in poorer countries.12
Preventing or favorably modifying coronary RFs through a combination of lifestyle modification and cardioprotective drug therapy, if appropriate, complemented by proactive public initiatives to enhance CV outcomes (eg, community wellness programs, healthier food choices and/or restaurant options, access to walking/bike paths, public smoking bans, recreation centers, farmers' markets, availability of automated external defibrillators, and adherence to environmental protection air quality standards), are now widely recognized as effective interventions aimed at the primordial, primary, and secondary prevention of CHD. Clearly, unhealthy lifestyle practices adversely influence not only blood pressure, lipid/lipoprotein levels, triglycerides, and glucose-insulin homeostasis, but also endothelial function, oxidative stress, inflammation (eg, C-reactive protein), and thrombosis/coagulation.2 In contrast, researchers have shown that a healthy lifestyle plays an important role in the primary prevention of CHD and risk of sudden cardiac death in middle-aged and older men and women, respectively, even among those taking medications for hypertension, hypercholesterolemia, or both.13,14 Among men, the elimination of 5 unhealthy lifestyle factors reduced CHD incidence by 87%.13 Others have reported that combining dietary therapy with drug treatment is more effective than drug treatment alone in improving brachial artery flow-mediated vasodilation,15 in correcting dyslipidemia,16,17 and in reducing ambulatory blood pressure18 and the risk of acute coronary syndromes.19 A dose-response association was also noted between increased cardiorespiratory fitness (CRF) in dyslipidemic patients treated and not treated with statins. Interestingly, the mortality impact of CRF was similar to that of statins and the combination of both therapies (statins and increased CRF) had an additive effect that was substantially greater than either therapy alone.20 In another study, the increased incidence of type 2 diabetes associated with statin use was eliminated by increased CRF.21 Moreover, systematic reviews have now shown that the mortality risk reductions associated with beneficial lifestyle changes in patients with CHD are similar to or greater than those reported for cardioprotective medications after acute myocardial infarction.22,23 Collectively, these data strongly support that the effects of favorable lifestyle modification and combination drug therapy on CV risk reduction are independent and additive.24–28 Some key studies that assessed the impact of a healthy lifestyle are summarized in Supplemental Digital Content 1 (available at: http://links.lww.com/JCRP/A153).29,30
RISK FACTORS AS HARBINGERS OF CARDIOVASCULAR DISEASE: DEBUNKING THE 50% MISCONCEPTION
Although it was commonly believed that only 50% of the risk of acute CV events could be predicted, both the INTERHEART31 and INTERSTROKE32 large case-control studies found that potentially modifiable RFs, including PA, accounted for ≥90% of the population attributable risks for myocardial infarction and stroke, respectively. Moreover, one widely-cited review concluded that 75-90% of CHD incidence is explained by traditional RFs.33 Framingham Heart Study participants with optimal levels of CV RFs at 50 yr of age were at very low risk of ever developing CVD, 5% and 8% for men and women, respectively.34 In contrast, for those with ≥2 major RFs, the elevated lifetime risk of developing CVD was 69% for men and 50% for women,34 mandating the adoption of healthy lifestyle habits (heart-healthy dietary practices, regular PA, avoidance/cessation of cigarette smoking) and complementary cardioprotective drug therapies, when appropriate. Collectively, these data and other relevant reports35,36 suggest that a more rigorous focus on these and the unhealthy behaviors that promote them has great potential to reduce the risk of initial and recurrent CV events.33,37 Although the medical community has been increasingly urged to amplify efforts to favorably modify major CV RFs in their patients,37 a large, international database reported that these harbingers of CVD remain largely undertreated and poorly controlled in many regions of the world, including the United States.38 Unfortunately, numerous studies now suggest that physicians and/or their allied health professional support staff often miss opportunities to counsel patients regarding the need for substantive lifestyle modification.39–43 It is time to change our emphasis from sick care to health care, with a greater focus on prevention and the foundational causes of CVD, as discussed in Supplemental Digital Content 2 (available at: http://links.lww.com/JCRP/A154).9,44–46
ADVISING PATIENTS REGARDING BEHAVIOR CHANGE: ASSESSING “READINESS TO CHANGE” UNHEALTHY LIFESTYLE HABITS
The inability or failure to discuss lifestyle modification during patient contact or ambulatory care visits may be attributed to several factors. Some medical professionals may be lacking in their personal lifestyle habits and may be hesitant to provide this type of counseling advice (eg, the obese physician, nurse, or physician assistant counseling patients on the need for weight reduction). Others, who may have little or no training in the specific skills sets required to facilitate behavior change, may be reluctant to broach this topic. In addition, most medical practices are already overburdened, reimbursement for patient counseling and education remains suboptimal, and use of the electronic medical record may further decrease face-to-face dialogue with patients.39 Diversity issues and treating patients of lower socioeconomic status may pose additional, unexpected challenges in counseling particular patient subsets.4,47 Yet, it appears that brief lifestyle counseling (eg, 3-5 min) by passionate, personable, and compassionate allied health professionals using proven behavior change strategies and interventions can be highly effective in achieving favorable patient outcomes.48 Perhaps it is time for the American Association of Cardiovascular and Pulmonary Rehabilitation, American Heart Association, American College of Sports Medicine, Preventive Cardiovascular Nurses Association, and other professional organizations to contemplate the development of training programs to promote certified lifestyle modification specialists that would work closely with and complement other health care providers to optimize preventive treatment interventions.
The likelihood that patients will or will not engage in a particular lifestyle behavior change is determined, in large part, by their expectations of the positive impact of that behavior in relation to their goals and objectives. Changing behavior is easier said than done; however, it is not impossible. Tailoring messages on lifestyle counseling to patient readiness to change increases the likelihood of success and favorable outcomes. The Transtheoretical Stages of Change Model49 includes 6 stages of intentional (or unintentional) behavior change that may occur over time (see Supplemental Digital Content 3, available at: http://links.lww.com/JCRP/A155).
Patients should be evaluated for their stage of readiness before being counseled to change a specific behavior. For example, the pre-contemplator may need additional knowledge, education, and motivation to achieve perception alteration, whereas a contemplator may require a critical analysis of the pros and cons of changing a specific behavior.
FACILITATING BEHAVIOR CHANGE
How do we engage our patients in actively making cardioprotective lifestyle changes? Behavioral studies have shown that such changes are often not linear or gradual in adoption, but rather progressive, regressive, spiraling, or static. Although most people believe that a single behavior change is preferred at any given time, embracing the notion that sequential changes can build on success, multiple simultaneous changes may be easier to adopt because they quickly yield perceptible benefits.50
Identifying and then reducing or eliminating real or perceived barriers to lifestyle change is critical to success. Lack of or a poor social support system is commonly associated with adverse outcomes in these patients.4,47,51 This may be overcome by mobilizing spousal and/or family support and encouraging patients to enroll in support groups such as weight loss or smoking cessation programs, PA clubs, or fitness groups. Financial difficulties are often reported by many patients as impediments to lifestyle change. Eating a heart healthy diet is more expensive and labor intensive than eating caloric-dense fast food. To overcome these barriers, patients must be systematic in acquiring food and schedule easily accessible leisure-time PA. Practitioners should also anticipate patients declaring that they do not have the time to engage in regular PA or make healthy lifestyle changes due to competing work-related and/or family caregiver responsibilities. Finally, failure to identify and address underlying psychosocial factors, especially depression and chronic stress, can be obstacles to a healthy lifestyle and directly promote or exacerbate atherosclerotic CHD.51
What are the most effective approaches to facilitate lifestyle changes in the patients we counsel? An Expert Working Group recommended the following: exercise-based primary or secondary prevention programs and a multidisciplinary team approach; motivational interviewing to increase intrinsic motivation and self-efficacy; baseline psychological assessment as a preface to encouraging patients to make behavioral lifestyle changes; and, friendly and positive interactions instead of negative messaging.52 The 2016 European guidelines for CVD prevention suggest that combining the knowledge and skills of physicians and allied professionals (such as nurses, psychologists, physician assistants, clinical exercise physiologists, and experts in nutrition, cardiac rehabilitation, and sports medicine) into multidisciplinary behavioral interventions can optimize CV outcomes.53 These guidelines provide 10 strategic steps to facilitate behavior change, which have been amplified herein (see the Table), and emphasize that communication training is important for staff involved in counseling patients. One helpful method is the 5 A's approach (see Supplemental Digital Content 4, available at: http://links.lww.com/JCRP/A156).54–63
Ten Strategic Steps to Facilitate Lifestyle Behavior Changea
||Develop a therapeutic alliance, with specific reference to socioeconomic, attitudinal, and cultural factors, as well as patient expectations of the benefits, costs, and consequences of the behavior change (or lack thereof)
||Counsel all individuals at risk for or with known cardiovascular disease using motivational interviewing, which can increase motivation and self-efficacy
||Help individuals to better understand the relationship between their lifestyle behaviors, medication compliance, and cardiovascular health outcomes
||Assist individuals to identify their specific barriers or impediments to behavior change, including a suboptimal social support system, financial challenges, or underlying psychosocial factors such as depression, anger, denial, chronic stress, or personality traits that can be obstacles to achieving a healthy lifestyle
||Strategize with the patient to identify realistic options to overcome these barriers, real or perceived, and gain commitments from them to favorably modify unhealthy habits
||Involve individuals in delineating deleterious lifestyle habits and abnormal risk factors that need to be changed
||Use varied counseling strategies including tailored messages and reinforcement of patient readiness for lifestyle change
||Design a written lifestyle modification plan, with specific reference to behaviors, timelines, and expected outcomes
||Involve other multidisciplinary staff, spouse/partner, family members, and friends, whenever possible
||Monitor progress through follow-up communications, including personal contact, phone messages, text messaging, e-mails, completion of dietary/smoking cessation logs, or combinations thereof
Adapted from Piepoli et al.53
Motivational interviewing is a therapeutic approach used by clinicians and allied health professionals during patient encounters to help encourage a behavioral transformation, generally to change long-standing unhealthy lifestyle habits.45,64,65 To accomplish this, the practitioner must convey understanding, acceptance, and interest in the patient as an individual and, if possible, mobilize spousal and family support for the identified and agreed-upon lifestyle changes.66 It is also important, early on, to assess social determinants of health outcomes, for example, limited education and/or low socioeconomic status,47 as well as clinical depression,51 since these characteristics have been shown to adversely impact lifestyle choices, RFs for premature death, and life expectancy.
The next step is to identify patient readiness to change behavior by using guided discussion and empathy to identify unhealthy lifestyle practices.67 An example would be expressing to an obese patient that you understand how difficult it is to stop binge eating and identifying triggers that stimulate the urge to overeat in that individual. Getting patients to consciously recognize the circumstances or scenarios that contribute to these behaviors is critical, along with getting them to understand and accept the need for change. Counterproductive arguments must be avoided during these consults, and interviewers should strive to encourage the patient to hear themselves express why they want to (or should) change.67 This is most effective using specific questions directed at patients about why they need to change this behavior. More importantly, the patient needs to be encouraged to self-reflect and speak, and responses pertaining to or highlighting self-responsibility or taking action should be reinforced by the provider.
The next steps involve helping the patient overcome inertia, identifying and rectifying impediments to lifestyle change and dealing with setbacks. These objectives are critical in helping him/her become independent and intrinsically motivated. An example would be to remind the relapsed smoker not to “quit quitting,” that setbacks line the road to success, and help them get back on track. Setting downscaled goals is the final step, that is, setting goals in stages, which can overcome inertia and be less daunting for the patient.39
OVERCOMING INERTIA WITH DOWNSCALED GOALS
For many patients, setting initial goals for RFs or lifestyle habits may be unrealistic and discouraging, especially if contemporary guideline recommendations are literally embraced. For example, using conventional norms, a 300-lb, inactive middle-aged man with a BMI of 45.5 kg/m2 might be counseled to reduce his body weight to a “normal” range (eg, 166 lb), since this would approximate a BMI of 25 kg/m2. Our approach would be to ask this patient about an initial weight goal he could realistically achieve, after he acknowledged the need for purposeful weight reduction. Regardless of his response, if it moved him in a downward direction, we would strongly agree with and support his goal. Similarly, rather than counseling this habitually sedentary, morbidly obese patient to exercise for ≥30 min/d on most d/wk, as current guidelines suggest, we might recommend 10-min light-to-moderate intensity exercise bouts, 3 d/wk, over the initial month of the exercise regimen. Recognize that in many ways, lifestyle modification, in this case regular exercise, may be analogous to the law of inertia: a body at rest tends to remain at rest, whereas a body in motion tends to remain in motion. We simply need to get patients to act. The easier we make it for the patient to act, the easier it will be to overcome inertia. Any action they take, no matter how trivial, may serve as a springboard to permanent lifestyle change.
In summary, patients should be directed to comprehensive programs designed to favorably modify unhealthy behaviors and facilitate CV risk reduction, including individually tailored interventions to circumvent or attenuate barriers to participation and adherence.68–71 Achieving these goals will, no doubt, involve providing research-based behavior change interventions to the patients we serve.39,45,46
We emphasize to patients that, the 10 most powerful 2-letter words in the English language are, “If it is to be, it is up to me.” In other words, take responsibility. Patients need to realize that they have the single greatest influence on their destiny relative to health outcomes.4 Its not genetic predisposition, social circumstances, environmental exposures, or, for that matter, access to quality health care.4 It is the decisions they make on a day-to-day basis, predominantly their behavioral choices. Thus, for lifestyle and RF modification to work, they simply need to know where they are at and the direction they need to go—that is the point in setting goals.
Perhaps the late General Norman Schwarzkopf summed it up best when asked how he would respond to an enemy attack. “Counterattack,” he replied. We would contend that when the enemy is chronic disease, including atherosclerotic CHD, the strategy is no different. The best counterattack is aggressive, long-term lifestyle modification complemented by adherence to prescribed metabolic and/or cardioprotective medications. Finally, it is important to emphasize to patients that time is an ally to successful lifestyle modification.39 Ordinary effort, that is, taking action on a day-to-day basis, can ultimately yield extraordinary results. Indeed, there is an enduring axiom of success in the field of personal achievement that says, “The universe rewards action.” This also represents a key tenet of successful lifestyle modification and achieving favorable health outcomes.
The authors thank Brenda White for her assistance with the preparation of this article.
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