Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association

Evaluation of the effectiveness of a problem-solving intervention addressing barriers to cardiovascular disease prevention behaviors in 3 underserved populations: Colorado, North Carolina, West Virginia, 2009

INTRODUCTION

In low-income and underserved populations, financial hardship and multiple competing roles and responsibilities lead to difficulties in lifestyle change for cardiovascular disease (CVD) prevention. To improve CVD prevention behaviors, we adapted, pilot-tested, and evaluated a problem-solving intervention designed to address barriers to lifestyle change.

METHODS

The sample consisted of 81 participants from 3 underserved populations, including 28 Hispanic or non-Hispanic white women in a western community (site 1), 31 African-American women in a semirural southern community (site 2), and 22 adults in an Appalachian community (site 3). Incorporating focus group findings, we assessed a standardized intervention involving 6-to-8 week group sessions devoted to problem-solving in the fall of 2009.

RESULTS

Most sessions were attended by 76.5% of participants, demonstrating participant adoption and engagement. The intervention resulted in significant improvement in problem-solving skills (P < .001) and perceived stress (P < .05). Diet, physical activity, and weight remained stable, although 72% of individuals reported maintenance or increase in daily fruit and vegetable intake, and 67% reported maintenance or increase in daily physical activity.

CONCLUSION

Study results suggest the intervention was acceptable to rural, underserved populations and effective in training them in problem-solving skills and stress management for CVD risk reduction.

Developing self-management education in coronary artery disease

We describe a three-step approach to develop and evaluate a novel coronary artery disease (CAD) self-management educational workbook. First, we conducted interviews using grounded theory methods with a diverse CAD cohort (n = 61) to identify needs and perceptions. Second, we developed the workbook, incorporating themes that emerged from the qualitative interviews. Finally, 225 people with CAD used the workbook in a longitudinal study and we evaluated their use of and experience with the workbook at 12 months. 12-month evaluation data revealed that the workbook: provided practical health information; enhanced behavior-specific self-efficacy; and reinforced that healthy behaviors decrease risk. Participants who read the workbook had greater within-patient increases in physical activity at 12-months compared with non-readers (p = 0.093) and among Black/Hispanic participants, workbook readers' increases were significant (592 vs. -645 kilocalories per week, p = 0.035). A self-management educational workbook developed using qualitative methods can provide relevant, disease-specific health information for patients with CAD.

Heart smart for women: a community-based lifestyle change intervention to reduce cardiovascular risk in rural women

PURPOSE

Cardiovascular disease (CVD) is the leading cause of death for rural women in the United States. Lifestyle change interventions in group settings focused on increasing physical activity and improving nutrition have been shown to help reduce the risk for CVD. This paper describes the implementation and evaluation of Heart Smart for Women (HSFW), a 12-week lifestyle behavior change intervention to reduce CVD risk for women in the rural southernmost 7 counties (S7) of Illinois.

METHODS

The HSFW evidence-based lifestyle intervention was delivered by a trained facilitator in 12 weekly 1-hour sessions to groups of women in the rural S7 region of Illinois. Dietary and physical activity assessments were collected at baseline, postintervention, and 1 year. Clinical measurements were taken at baseline, 6 months and 1 year. Data were analyzed for change in behavioral and clinical outcomes over time.

FINDINGS

In total, 162 women completed HSFW in 13 communities across the S7 region. HSFW participants showed improvement in dietary and physical activity indicators at the end of the 12-week intervention, but only increases in vegetable consumption and physical activity were sustained over 1 year. A decrease in total cholesterol was observed at 6 months but not maintained at 1 year.

CONCLUSIONS

HSFW led to short-term, moderate changes in nutrition and physical activity in rural women, but some health improvements were not sustained at 1 year. These findings suggest that more intensive follow-up maybe required to help maintain long-term behavior change, especially in rural areas where women are geographically dispersed.

Relative importance of step count, intensity, and duration on physical activity's impact on vascular structure and function in previously sedentary older adults

BACKGROUND

Age-related endothelial dysfunction and vascular stiffening are associated with increased cardiovascular (CV) risk. Many groups have encouraged goals of ≥10 000 steps/day or ≥30 min/day of moderate intensity physical activity (MPA) to reduce age-related CV risk. The impact of MPA on the vasculature of older adults remains unclear.

METHODS AND RESULTS

We randomized 114 sedentary older adults ages ≥50 to 12 weeks of either no intervention (group 1), a pedometer-only intervention (group 2), or a pedometer with an interactive website employing strategies to increase the adoption of habitual physical activity (PA, group 3). Endothelial function by brachial flow-mediated dilation (FMD%), vascular stiffness by tonometry, step-count by pedometer, and PA intensity/distribution by accelerometer were measured. Step-count increased in groups 2 (5136±1554 to 9596±3907, P<0.001) and 3 (5474±1512 to 8167±3111, P<0.001) but not in group 1 (4931±1667 to 5410±2410). Both groups 2 and 3 increased MPA ≥30 min/day. Only group 3 increased MPA in continuous bouts of ≥10 minutes (P<0.001) and improved FMD% (P=0.001). Neither achievement of ≥10 000 steps/day nor ≥30 min/day of MPA resulted in improved FMD%. However, achieving ≥20 min/day in MPA bouts resulted in improved FMD%. No changes in vascular stiffness were observed.

CONCLUSIONS

MPA reverses age-related endothelial dysfunction, but may require MPA to be performed in bouts of ≥10 minutes duration for ≥20 min/day to be effective. Commonly encouraged PA goals do not guarantee improved endothelial function and may not be as effective in reducing CV risk.

CLINICAL TRIAL REGISTRATION URL

Clinicaltrials.gov. UNIQUE IDENTIFIER: NCT-01212978.

Evaluation of an individualised programme to promote self-care in sleep-activity in patients with coronary artery disease -- a randomised intervention study

AIMS AND OBJECTIVES

To evaluate the effectiveness of an individualised programme to promote self-care in sleep-activity in patients with coronary artery disease.

BACKGROUND

Recent scientific findings have shown that low physical exercise and stress interfere with coronary artery disease patients' sleep quality and sleep efficiency independent of gender, age and co-morbidity.

DESIGN

A randomised pretest-post-test control design.

METHODS

Forty-seven patients who had undergone a coronary revascularisation procedure and/or pharmacological treatment three to seven weeks earlier at a general hospital were randomised to either an intervention group or a control group. Data collection was carried out by questionnaires, a study-specific sleep diary and actigraphy registration for 10 consecutive 24-hour periods, with a follow-up after three to four months. The intervention group underwent a nurse-led individualised education programme to promote self-care of sleep-activity. Sleep habits and sleep-related lifestyle together formed the basis for setting up individual goals together with the nurse. Individual advice on physical training, relaxation exercise and a CD-based relaxation programme was provided by a physiotherapist. Both groups received a brochure about sleep and stress.

RESULTS

At a three- to four-month follow-up, the main improvements were seen in the intervention group regarding sleep quality, sleep duration and sleep efficiency in the sleep diary and sleep efficiency in actigraphy. Statistical improvements in health-related quality of life were revealed. This was not so obvious in the control group.

CONCLUSIONS

An individualised intervention programme to promote self-care of sleep-activity including relaxation in patients with coronary artery disease led by a nurse may improve sleep quality. However, a longitudinal study to promote self-care in sleep-activity should be performed using a larger sample and multiple sites with continuous follow-ups to determine whether any positive effects remain stable over time.

RELEVANCE TO CLINICAL PRACTICE

Implementation of a multiprofessional individualised programme to promote self-care of sleep-activity including relaxation based on patients' needs, supported by a healthcare team and led by nurses, is important in clinical practice.

"Go4Life" exercise counseling, accelerometer feedback, and activity levels in older people

Older people are more sedentary than other age groups. We sought to determine if providing an accelerometer with feedback about activity and counseling older subjects using Go4Life educational material would increase activity levels. Participants were recruited from independent living areas within assisted living facilities and the general public in the Rochester, MN area. 49 persons aged 65-95 (79.5±7.0 years) who were ambulatory but sedentary and overweight participated in this randomized controlled crossover trial for one year. After a baseline period of 2 weeks, group 1 received an accelerometer and counseling using Go4Life educational material (www.Go4Life.nia.nih.gov) for 24 weeks and accelerometer alone for the next 24 weeks. Group 2 had no intervention for the first 24 weeks and then received an accelerometer and Go4Life based counseling for 24 weeks. There were no significant baseline differences between the two groups. The intervention was not associated with a significant change in activity, body weight, % body fat, or blood parameters (p>0.05). Older (80-93) subjects were less active than younger (65-79) subjects (p=0.003). Over the course of the 48 week study, an increase in activity level was associated with a decline in % body fat (p=0.008). Increasing activity levels benefits older patients. However, providing an accelerometer and a Go4Life based exercise counseling program did not result in a 15% improvement in activity levels in this elderly population. Alternate approaches to exercise counseling may be needed in elderly people of this age range.

Physical activity: practice this idea

Sedentary habits or insufficient activities to promote health benefits can influence the occurrence of chronic diseases. The cardiovascular risk factors arise, at least partially, from the individual-environment interaction during life, and worsen with aging and lack of physical exercise. Health promotion and prevention are among the greatest challenges of public health policies. However, physical activity turns out to be rarely recommended and, thus have a very poor adhesion. In spite of consensus about the benefits of physical activity in both primary and secondary prevention, only 32% of adults and 66% of children and adolescents, according to Healthy People 2010 guideline, practice leisure-time physical activity. Thus, the regular practice of physical activity and healthy habits require changes in basic concepts in government and social policies. The higher involvement of public and private sectors related to health and education, the more expressive would be the reduction in socioeconomic costs and the improvement in quality of life.

Physical Activity and Health in Women

Medical authorities advise US adults to perform a minimum of 30 minutes of moderate-intensity aerobic physical activity on most days of the week to improve health and reduce risk for many chronic conditions. New findings from epidemiologic studies suggest that physical activity not only reduces the risk of developing coronary heart disease, stroke, and type 2 diabetes but also may prevent certain cancers (including colon and breast cancer), osteoporotic fracture, falls, cognitive decline, mood disturbances, and adverse pregnancy outcomes. Physical activity is important for regulating body weight, but many cardiometabolic benefits of exercise are independent of such regulation. This article reviews recent epidemiologic evidence on physical activity with respect to a variety of health outcomes in women and concludes with guidance for clinicians seeking to boost activity levels in sedentary patients. However, additional research is needed on features of individual- and community-based interventions and policies that successfully promote healthful levels of physical activity.

Effect of an intervention to improve the cardiovascular health of family members of patients with coronary artery disease: a randomized trial

BACKGROUND

Family members of patients with coronary artery disease (CAD) have higher risk of vascular events. We conducted a trial to determine if a family heart-health intervention could reduce their risk of CAD.

METHODS

We assessed coronary risk factors and randomized 426 family members of patients with CAD to a family heart-health intervention (n = 211) or control (n = 215). The intervention included feedback about risk factors, assistance with goal setting and counselling from health educators for 12 months. Reports were sent to the primary care physicians of patients whose lipid levels and blood pressure exceeded threshold values. All participants received printed materials about smoking cessation, healthy eating, weight management and physical activity; the control group received only these materials. The main outcomes (ratio of total cholesterol to high-density lipoprotein [HDL] cholesterol; physical activity; fruit and vegetable consumption) were assessed at 3 and 12 months. We examined group and time effects using mixed models analyses with the baseline values as covariates. The secondary outcomes were plasma lipid levels (total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol and triglycerides); glucose level; blood pressure; smoking status; waist circumference; body mass index; and the use of blood pressure, lipid-lowering and smoking cessation medications.

RESULTS

We found no effect of the intervention on the ratio of total cholesterol to HDL cholesterol. However, participants in the intervention group reported consuming more fruit and vegetables (1.2 servings per day more after 3 mo and 0.8 servings at 12 mo; p < 0.001). There was a significant group by time interaction for physical activity (p = 0.03). At 3 months, those in the intervention group reported 65.8 more minutes of physical activity per week (95% confidence interval [CI] 47.0-84.7 min). At 12 months, participants in the intervention group reported 23.9 more minutes each week (95% CI 3.9-44.0 min).

INTERPRETATION

A health educator-led heart-health intervention did not improve the ratio of total cholesterol to HDL cholesterol but did increase reported physical activity and fruit and vegetable consumption among family members of patients with CAD. Hospitalization of a spouse, sibling or parent is an opportunity to improve cardiovascular health among other family members.

TRIAL REGISTRATION

clinicaltrials.gov, no NCT00552591.

Mediterranean Diet and Workplace Health Promotion

Analytical and experimental studies confirm relationships between the consumption of certain foods and cardiovascular disease, diabetes, and cancer. Mediterranean diet patterns have long been associated with a reduced risk of major diseases and many favorable health outcomes. Data from observational, longitudinal, and randomized controlled trials have demonstrated that Mediterranean-style diets can improve body mass index and body weight, reduce the incidence of diabetes mellitus and metabolic syndrome risk factors, decrease cardiovascular morbidity and coronary heart disease mortality, as well as decrease all-cause mortality. Recently, efforts have attempted to improve dietary habits in the workplace, by modifying food selection, eating patterns, meal frequency, and the sourcing of meals taken during work. Evidence supporting the Mediterranean diet and the potential cardioprotective role of healthier diets in the workplace are reviewed here, and promising strategies to improve metabolic and cardiovascular health outcomes are also provided.

Consumer health information technology in an adult public health primary care clinic: a heart health education feasibility study

OBJECTIVE

To explore the feasibility and short term outcomes of using an interactive kiosk integrated into office flow to deliver health information in a primary care clinic.

METHODS

Fifty-one adults with BMI ≥25 were randomly assigned to use a kiosk with attached devices to receive a six-week healthy eating/weight monitoring (intervention) or general health/BP monitoring (attention-control) program. Outcomes were measured at baseline, 8 weeks (post) and three month follow-up.

RESULTS

Participants completed an average of 2.73 weekly sessions, with transportation and time given as limiting factors. They found the kiosk easy to use (97%), liked the touchscreen (94%), and would use the kiosk again (81%). Although there were no differences between groups, the 27 completing all assessments showed reduced weight (p=.02), and decreased systolic (p=.01) and diastolic BP (p<.001) at follow-up. Although healthy eating behaviors increased, the change was not statistically significant.

CONCLUSION

Using a kiosk within a clinic setting is a feasible method of providing health information and self-monitoring. Multi-session educational content can provide beneficial short-term outcomes in overweight adults.

PRACTICE IMPLICATIONS

A kiosk with attached peripherals in a clinic setting is a viable adjunct to provider education, particularly in medically underserved areas.

Dietary fiber intake and cardiometabolic risks among US adults, NHANES 1999-2010

BACKGROUND

Dietary fiber may decrease the risk of cardiovascular disease and associated risk factors. We examined trends in dietary fiber intake among diverse US adults between 1999 and 2010, and investigated associations between dietary fiber intake and cardiometabolic risks including metabolic syndrome, cardiovascular inflammation, and obesity.

METHODS

Our cross-sectional analysis included 23,168 men and nonpregnant women aged 20+ years from the 1999-2010 National Health and Nutrition Examination Survey. We used weighted multivariable logistic regression models to estimate predicted marginal risk ratios and 95% confidence intervals for the risks of having the metabolic syndrome, inflammation, and obesity associated with quintiles of dietary fiber intake.

RESULTS

Consistently, dietary fiber intake remained below recommended adequate intake levels for total fiber defined by the Institute of Medicine. Mean dietary fiber intake averaged 15.7-17.0 g. Mexican Americans (18.8 g) consumed more fiber than non-Hispanic whites (16.3 g) and non-Hispanic blacks (13.1 g). Comparing the highest with the lowest quintiles of dietary fiber intake, adjusted predicted marginal risk ratios (95% confidence interval) for the metabolic syndrome, inflammation, and obesity were 0.78 (0.69-0.88), 0.66 (0.61-0.72), and 0.77 (0.71-0.84), respectively. Dietary fiber was associated with lower levels of inflammation within each racial and ethnic group, although statistically significant associations between dietary fiber and either obesity or metabolic syndrome were seen only among whites.

CONCLUSIONS

Low dietary fiber intake from 1999-2010 in the US, and associations between higher dietary fiber and a lower prevalence of cardiometabolic risks suggest the need to develop new strategies and policies to increase dietary fiber intake.

Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study

Objectives

This study estimated the association of cardiovascular health behaviors with the risk of all-cause and cardiovascular disease (CVD) mortality in middle-aged men in Korea.

Methods

In total, 12 538 men aged 40 to 59 years were enrolled in 1993 and followed up through 2011. Cardiovascular health metrics defined the following lifestyle behaviors proposed by the American Heart Association: smoking, physical activity, body mass index, diet habit score, total cholesterol, blood pressure, and fasting blood glucose. The cardiovascular health metrics score was calculated as a single categorical variable, by assigning 1 point to each ideal healthy behavior. A Cox proportional hazards regression model was used to estimate the hazard ratio of cardiovascular health behavior. Population attributable risks (PARs) were calculated from the significant cardiovascular health metrics.

Results

There were 1054 total and 171 CVD deaths over 230 690 person-years of follow-up. The prevalence of meeting all 7 cardiovascular health metrics was 0.67%. Current smoking, elevated blood pressure, and high fasting blood glucose were significantly associated with all-cause and CVD mortality. The adjusted PARs for the 3 significant metrics combined were 35.2% (95% confidence interval [CI], 21.7 to 47.4) and 52.8% (95% CI, 22.0 to 74.0) for all-cause and CVD mortality, respectively. The adjusted hazard ratios of the groups with a 6-7 vs. 0-2 cardiovascular health metrics score were 0.42 (95% CI, 0.31 to 0.59) for all-cause mortality and 0.10 (95% CI, 0.03 to 0.29) for CVD mortality.

Conclusions

Among cardiovascular health behaviors, not smoking, normal blood pressure, and recommended fasting blood glucose levels were associated with reduced risks of all-cause and CVD mortality. Meeting a greater number of cardiovascular health metrics was associated with a lower risk of all-cause and CVD mortality.

Cardiac rehabilitation past, present and future: an overview

Cardiac Rehabilitation has evolved over the past decades from a simple monitoring for the safe return to physical activities to a multidisciplinary approach that focuses on patient education, individually tailored exercise training, modification of the risk factors and the overall well-being of the cardiac patients. It has been proven to be an effective tool for the care of the patients with heart disease. Recent research in cardiac rehabilitation has demonstrated that tremendous benefits can be derived from the optimal use of cardiac rehabilitation in patients with various cardiac pathologies including ischemic heart disease, heart failure and post heart surgery. The benefits of cardiac rehabilitation include mortality reduction, symptom relief, reduction in smoking and improved exercise tolerance, risk factors modification and the overall psychosocial wellbeing. Unfortunately, cardiac rehabilitation remains considerably underutilized mainly because of referral problems and poor enrollment. The development of alternate approaches and the use of transtelephonic and other means of monitoring and surveillance will help expand the utilization of cardiac rehabilitation.

Long-term effectiveness of the community-based Complete Health Improvement Program (CHIP) lifestyle intervention: a cohort study

OBJECTIVE

To examine the long-term (three or more years) effectiveness of the volunteer-delivered Complete Health Improvement Program (CHIP) intervention.

DESIGN

Cohort study.

SETTING

Hawera, New Zealand.

PARTICIPANTS

Of the total cohort of 284 individuals who self-selected to complete the CHIP lifestyle intervention between 2007 and 2009, 106 (37% of the original cohort, mean age=64.9±7.4 years, range 42-87 years; 35% males, 65% female) returned in 2012 for a complimentary follow-up health assessment (mean follow-up duration=49.2+10.4 months).

INTERVENTION

30-day lifestyle modification programme (diet, physical activity, substance use and stress management) delivered by volunteers in a community setting.

MAIN OUTCOME MEASURES

Changes in body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP), fasting plasma glucose (FPG), total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglycerides (TG).

RESULTS

After approximately 4 years, participants with elevated biometrics at programme entry maintained significantly lowered BMI (-3.2%; 34.8±5.4 vs 33.7±5.3 kg/m(2), p=0.02), DBP (-9.4%; 89.1±4.1 vs 80.8±12.6 mm Hg, p=0.005), TC (-5.5%; 6.1±0.7 vs 5.8±1.0 mmol/L, p=0.04) and TG (-27.5%; 2.4±0.8 vs 1.7±0.7 mmol/L, p=0.002). SBP, HDL, LDL and FPG were not significantly different from baseline. Participants with elevated baseline biometrics who reported being compliant to the lifestyle principles promoted in the intervention (N=71, 67% of follow-up participants) recorded further reductions in BMI (-4.2%; 34.8±4.5 vs 33.4±4.8 kg/m(2), p=0.02), DBP (-13.3%; 88.3±3.2 vs 77.1±12.1 mm Hg, p=0.005) and FPG (-10.4%; 7.0±1.5 vs 6.3±1.3 mmol/L, p=0.02).

CONCLUSIONS

Individuals who returned for follow-up assessment and entered the CHIP lifestyle intervention with elevated risk factors were able to maintain improvements in most biometrics for more than 3 years. The results suggest that the community-based CHIP lifestyle intervention can be effective in the longer term, even when delivered by volunteers.

Are lifestyle interventions in primary care cost-effective?--An analysis based on a Markov model, differences-in-differences approach and the Swedish Björknäs study

BACKGROUND

Lifestyle interventions affect patients' risk factors for metabolic syndrome (MeSy), a pre-stage to cardiovascular diseases, diabetes and related complications. An effective lifestyle intervention is the Swedish Björknäs intervention, a 3-year randomized controlled trial in primary care for MeSy patients. To include future disease-related cost and health consequences in a cost-effectiveness analysis, a simulation model was used to estimate the short-term (3-year) and long-term (lifelong) cost-effectiveness of the Björknäs study.

METHODOLOGY/ PRINCIPAL FINDINGS

A Markov micro-simulation model was used to predict the cost and quality-adjusted life years (QALYs) for MeSy-related diseases based on ten risk factors. Model inputs were levels of individual risk factors at baseline and at the third year. The model estimated short-term and long-term costs and QALYs for the intervention and control groups. The cost-effectiveness of the intervention was assessed using differences-in-differences approach to compare the changes between the groups in the health care and societal perspectives, using a 3% discount rate. A 95% confidence interval (CI), based on bootstrapping, and sensitivity analyses describe the uncertainty in the estimates. In the short-term, costs are predicted to increase over time in both groups, but less in the intervention group, resulting in an average cost saving/reduction of US$-700 (in 2012, US$1=six point five seven SEK) and US$-500, in the societal and health care perspectives. The long-term estimate also predicts increased costs, but considerably less in the intervention group: US$-7,300 (95% CI: US$-19,700 to US$-1,000) in the societal, and US$-1,500 (95% CI: US$-5,400 to US$2,650) in the health care perspective. As intervention costs were US$211 per participant, the intervention would result in cost saving. Furthermore, in the long-term an estimated 0.46 QALYs (95% CI: 0.12 to 0.69) per participant would be gained.

CONCLUSIONS/ SIGNIFICANCE

The Swedish Björknäs study appears to reduce demands on societal and health care resources and increase health-related quality of life.

Is high-intensity exercise better than moderate-intensity exercise for weight loss?

This viewpoint debates the state-of-the-art research focusing on the optimal intensity of the exercise programs for inducing a sustained weight or fat-mass loss in overweight/obese people. In our demanding society, the most attractive messages in the popular press are those promising the best results in a short time. This might explain the emphasis given by media to those scientific articles that report the efficacy on weight loss of exercise programs by their shorter duration and higher intensity. However, in the literature on overweight or obese people, there is little conclusive evidence for more favorable effects with high-intensity training than with continuous moderate-intensity exercise on body weight or fat mass loss. Since both exercise protocols have been demonstrated as useful to reduce body weight, the decision on the intensity of exercise prescription should be individualized and based on outcomes different from fat or weight loss. In this regard, there are pro and contra arguments for the prescription of high-intensity aerobic exercise in obese people. Among the pro arguments, is the demonstration that, in several studies, high-intensity training appears to induce superior improvements in aerobic fitness. Among the contra arguments to prescribe high-intensity exercise is the demonstration that prescribing a higher-intensity exercise decreases adherence and results in the completion of less exercise. Thus, a successful exercise program should be proposed at a moderate intensity and a low perceived effort because obese subjects who have low self-efficacy, poor mood status, and are not familiar with high-intensity workouts could easily drop out.

Lifestyle medicine: the future of chronic disease management

PURPOSE OF REVIEW

Lifestyle medicine is a new discipline that has recently emerged as a systematized approach for management of chronic disease. The practice of lifestyle medicine requires skills and competency in addressing multiple health risk behaviours and improving self-management. Targets include diet, physical activity, behaviour change, body weight control, treatment plan adherence, stress and coping, spirituality, mind body techniques, tobacco and substance abuse. This review focuses on the impact of a healthy lifestyle on chronic disease, the rarity of good health and the challenges of implementing a lifestyle medicine programme.

RECENT FINDINGS

Unhealthy lifestyle behaviours are at the root of the global burden of noncommunicable diseases and account for about 63% of all deaths. Over the past several years, there has been an increased interest in evaluating the benefit of adhering to 'low-risk lifestyle' behaviours and ideal 'cardiovascular health metrics'. Although a healthy lifestyle has repeatedly been shown to improve mortality, the population prevalence of healthy living remains low.

SUMMARY

Lifestyle medicine presents a new and challenging approach to address the prevention and treatment of noncommunicable diseases, the most important and prevalent causes for increased morbidity and mortality worldwide.

Psychodynamic Motivation and Training program (PMT) for the secondary prevention in patients with stable coronary heart disease: study protocol for a randomized controlled trial of feasibility and effects

BACKGROUND

Nonpharmacological secondary prevention of coronary heart disease is considered a safe and effective measure to substantially reduce mortality. Despite the effectiveness of lifestyle changes, the compliance rate of patients is very low mainly due to psychosocial barriers. Psychotherapeutic approaches that address how persons think about themselves and their behaviors appear to have a significant potential for improving health behavior.

METHODS/DESIGN

Against this background, our study aims to examine the feasibility and effects of a Psychodynamic Motivation and Training program (PMT) as compared to one session of advice in exercise training (EX) and treatment as usual (TAU). For that purpose, 90 patients with stable coronary heart disease and a physically inactive lifestyle will be randomly assigned to the three groups (each with n = 30). The primary outcome is the change in the individual anaerobic threshold as determined by spiroergometry from baseline to six month follow-up. Secondary endpoints include change in endothelial function, biomarkers of inflammation and oxidative stress, quality of life, symptoms of fatigue, illness perception and feasibility of the treatment approach. We hypothesize that physical fitness will improve more in PMT than in EX and TAU, with PMT and EX more than TAU, and that the effects will be more pronounced for participants with current mental or psychosocial distress.

DISCUSSION

The results of the study will help to determine the effectiveness of a psychodynamic lifestyle change approach and to identify measures for designing specifically tailored interventions to improve compliance with cardiovascular prevention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01445808.

The South Asian Heart Lifestyle Intervention (SAHELI) study to improve cardiovascular risk factors in a community setting: design and methods

Disseminating and implementing evidence-based, cardiovascular disease (CVD) prevention lifestyle interventions in community settings and in ethnic minority populations is a challenge. We describe the design and methods for the South Asian Heart Lifestyle Intervention (SAHELI) study, a pilot study designed to determine the feasibility and initial efficacy of a culturally-targeted, community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians (SAs). Participants with at least one CVD risk factor will be randomized to either a lifestyle intervention or a control group. Participants in both groups will be screened in a community setting and receive a primary care referral after randomization. Intervention participants will receive 6weeks of group classes, followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal. Control participants will receive their screening results and monthly mailings on CVD prevention. Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline, 3-, and 6-month follow-up. Secondary outcomes will be changes in weight, clinical risk factors, primary care visits, self-efficacy, and social support. This study will be one of the first to pilot-test a lifestyle intervention for SAs, one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk. Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population.

Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: a randomized clinical trial

BACKGROUND

Nurse-led interventions have proven beneficial to reduce estimated cardiovascular risk.

AIM

The purpose of this study was to evaluate the effect of systematic, nurse-led individual lifestyle counseling sessions on the reduction of 10-year cardiovascular risk scores in patients with coronary artery disease (CAD).

METHODS

This was a randomized clinical trial of CAD patients treated at a tertiary referral hospital. The intervention group received nurse-led guidance by means of five face-to-face sessions and telephone contact over the course of one year, starting three months after hospital discharge. Exercise and dietary goals were set for each patient and monitored at each session. The control group received standard medical advice. Patients were stratified by Framingham risk score and compared at the end of the follow-up period.

RESULTS

The final sample comprised 74 patients, 38 in the intervention group and 36 in the control group. Mean age was 58 ± 9 years; 74% of patients were male. A 1.7 point (-13.6%) reduction in risk score was recorded in the intervention group, vs a 1.2 point increase in risk score (+11%) in the control group (p=0.011). Significant between-group differences were detected for weight (intervention, 78 ± 14 kg at baseline vs 77 ± 14 kg at study end; control, 78 ± 15 kg vs 79 ± 15 kg; p=0.04), systolic blood pressure (intervention, 136 ± 22 mm Hg vs 124 ± 15 mm Hg; control, 126 ± 15 mm Hg vs 129 ± 16 mm Hg; p=0.005), and diastolic blood pressure (intervention, 82 ± 10 mm Hg vs 77 ± 09 mm Hg; control, 79 ± 09 mm Hg vs 80 ± 10 mm Hg; p=0.02).

CONCLUSION

Structured and systematic nurse-led lifestyle counseling effectively reduced cardiovascular risk score.

Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation

PURPOSE

To identify the incidence of adverse events (AE) that occurred in stroke survivors during the first year following discharge from inpatient rehabilitation and to determine the type and patterns of AE.

METHODS

Data were collected for 12 months on events resulting in admissions to the emergency department, hospital, long-term care facility, or death. Descriptive statistics were used to depict the patterns of AE and univariate comparisons were made of the differences between survivors who did or did not experience one or more AE.

RESULTS

Of the 159 participants, 50% reported a total of 163 AE. Most AE (82.2%) were unexpected and the majority occurred during the first 6 months; 12 recurrent strokes and 6 transient ischemic attacks occcurred.

CONCLUSIONS

Education on prevention and treatment of common AE is important prior to discharge. Anticipatory guidance may help survivors and caregivers modify their lifestyle and prevent common AE.

Sedentary behaviours and obesity in adults: the Cardiovascular Risk in Young Finns Study

OBJECTIVE

Sedentary behaviour may contribute to the development of obesity. We investigated the relations between different types of sedentary behaviour and adiposity markers in a well-characterised adult population after controlling for a wide range of potential confounders.

DESIGN

Cross-sectional study.

SETTING

The Cardiovascular Risk in Young Finns Multicenter Study. Participants Sedentary time (TV viewing, computer time, reading, music/radio listening and other relaxation) was assessed with a questionnaire for 1084 women and 909 men aged 30-45 years. Other study variables included occupational and leisure-time physical activity, sleep duration, socioeconomic status, smoking, alcohol consumption, energy intake, adherence to the recommended diet, multiple individual food items, age and genetic variants associated with body mass index (BMI). Primary outcome measures BMI in kg/m(2) and waist circumference (WC in cm).

RESULTS

Of the different sedentary behaviour types, TV viewing was most consistently related to higher BMI and WC, both in men and women. One additional daily TV hour was associated with a 1.81±0.44 cm larger WC in women and 2 cm±0.44 cm in men (both p<0.0001). The association with TV was diluted, but remained highly significant after adjustments with all measured covariates, including several potentially obesogenic food items associated with TV viewing. The intakes of food items such as sausage, beer and soft drinks were directly associated with TV viewing, while the intakes of oat and barley, fish, and fruits and berries were associated indirectly. After these adjustments, non-TV sedentary behaviour remained associated with adiposity indices only in women.

CONCLUSIONS

Out of the different types of sedentary behaviour, TV viewing was most consistently associated with adiposity markers in adults. Partial dilution of these associations after adjustments for covariates suggests that the obesogenic effects of TV viewing are partly mediated by other lifestyle factors.

Factors that influence obesity, functional capacity, anxiety and depression outcomes following a Phase III cardiac rehabilitation programme

AIMS AND OBJECTIVES

To examine changes in functional capacity, anxiety, depression and BMI in patients who completed a cardiac rehabilitation programme and to determine the influencing factors.

BACKGROUND

While the effectiveness of cardiac rehabilitation is long established, more studies are needed to examine the combined effectiveness of this multicomponent intervention and the factors that influence this in the changed profile of patients currently attending cardiac rehabilitation.

DESIGN

The study was a longitudinal retrospective study of patients following a six- or eight-week Phase III cardiac rehabilitation programme.

METHODS

The study recruited 154 patients. Functional capacity, anxiety, depression, weight, waist circumference and BMI were assessed at the beginning and end of cardiac rehabilitation. t-tests were used to assess changes over time, and multivariate regression analysis was used to determine the influence of factors on these changes.

RESULTS

Significant improvements were seen in functional capacity, waist circumference, weight and BMI, but not in depression and anxiety. Multivariate analysis revealed that being younger and less fit was associated with greater improvements in functional capacity while reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Models testing the influence of the factors on BMI, anxiety and depression were not significant.

CONCLUSION

Cardiac rehabilitation is still an effective method to instigate changes in cardiac risk factors despite the changes in patients profile attending programmes.

RELEVANCE TO CLINICAL PRACTICE

Continued encouragement of the historically less typical patients to participate in cardiac rehabilitation is needed as reason for referral, gender, depression or BMI did not influence improvements in functional capacity. Despite psychosocial components within the programme, no significant improvements were observed over cardiac rehabilitation in depression or anxiety. While effectiveness was observed, there is room for further optimisation of practice and research by employing and documenting clearly the use of behavioural techniques.

Social cognitive changes following weight loss and physical activity interventions in obese, older adults in poor cardiovascular health

BACKGROUND

The study objectives were to determine (a) the effects of group-mediated cognitive-behavioral interventions on change in performance self-efficacy, satisfaction with function, and with appearance among older, overweight/obese adults in poor cardiovascular health and (b) whether self-efficacy mediated change in 400-m walk time.

METHODS

This translational, randomized controlled trial of physical activity and weight loss was conducted within community Cooperative Extension Centers. Participants were randomized to three intervention arms: Physical Activity, Weight Loss + Physical Activity, or a Successful Aging education control.

RESULTS

Across 18 months, the Weight Loss + Physical Activity intervention demonstrated greater improvements in self-efficacy, satisfaction with function, and appearance versus other trial arms. Physical Activity intervention participants also experienced significant improvements in self-efficacy and satisfaction with function versus those in Successful Aging. Self-efficacy mediated 400-m walk time at 18 months.

CONCLUSIONS

Both group-mediated cognitive-behavioral interventions yielded desirable improvements in social cognitions and preserved mobility improvements post-intervention.

Prevalence of the American Heart Association's "ideal cardiovascular health" metrics in a rural, cross-sectional, community-based study: the Heart of New Ulm Project

Background

The American Heart Association (AHA) recently created the construct of “ideal cardiovascular health” based on 7 cardiovascular health metrics to measure progress toward their 2020 Impact Goal. The present study applied this construct to assess the baseline cardiovascular health of a rural population targeted with a community‐based cardiovascular disease prevention program.

Methods and Results

The sample consists of 4754 New Ulm, Minn, adult residents who participated in either the 2009 or 2011 community heart health screenings offered by the Hearts Beat Back: The Heart of New Ulm (HONU) Project (mean age 52.1 years, 58.3% women). Data collected at the screenings were analyzed to replicate the AHA's ideal cardiovascular health measure and the 7 metrics that comprise the construct. Screening participants met, on average (±SD), 3.4 (±1.4) ideal cardiovascular health metrics. Only 1.0% of participants met the AHA's definition of ideal health in all metrics and 7.1% met ≤1 ideal health metric. Higher proportions of women met the ideal category in all metrics except physical activity. Women over the age of 60 were less likely to meet the ideal category for cholesterol and hypertension than were men in the same age range.

Conclusion

Prevalence of ideal cardiovascular health is extremely low in this rural population. To make progress toward the 2020 Impact Goal, targeted community‐based interventions must be implemented based on the most prevalent cardiovascular risk factors.

Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12-month post-intervention follow-up

BACKGROUND

Intensive diet and physical activity interventions have been found to reduce cardiovascular disease (CVD) risk, but are resource intensive. The American Heart Association recently recommended motivational interviewing (MI) as an effective approach for low-intensity interventions to promote health-related outcomes such as weight loss. However, there is limited research evaluating the long-term effectiveness of MI-based interventions on health-related outcomes associated with CVD risk. The current research evaluated the effectiveness of a six-month low-intensity MI intervention in a UK primary-care setting in maintaining reductions in CVD risk factors at12 months post-intervention.

METHODS

Primary-care patients were randomised to an intervention group that received standard exercise and nutrition information plus up to five face-to-face MI sessions, delivered by a physical activity specialist and registered dietician over a 6-month period, or to a minimal intervention comparison group that received the standard information only. Follow-up measures of behavioural (vigorous and moderate physical activity, walking, physical activity stage-of-change, fruit and vegetable intake, and dietary fat intake) and biomedical (weight, body mass index [BMI], blood pressure, cholesterol) outcomes were taken immediately post-intervention and at a 12-month follow-up occasion.

RESULTS

Intent-to-treat analyses revealed significant differences between groups for walking and cholesterol. Obese and hypercholesterolemic patients at baseline exhibited significant improvements in BMI and cholesterol respectively among those allocated to the intervention group compared to the comparison group. Post-intervention improvements in other health-related outcomes including blood pressure, weight, and BMI were not maintained.

CONCLUSIONS

The present study suggests that a low-intensity MI counselling intervention is effective in bringing about long-term changes in some, but not all, health-related outcomes (walking, cholesterol levels) associated with CVD risk. The intervention was particularly effective for patients with elevated levels of CVD risk factors at baseline. Based on these findings future interventions should be conducted in a primary care setting and target patients with high risk of CVD. Future research should investigate how the long-term gains in health-related outcomes brought about by the MI-counselling intervention in the current study could be extended to a wider range of health outcomes.

Churches as targets for cardiovascular disease prevention: comparison of genes, nutrition, exercise, wellness and spiritual growth (GoodNEWS) and Dallas County populations

BACKGROUND

We compared cardiovascular (CV) risk factors (CVRFs) of community-based participatory research (CBPR) participants with the community population to better understand how CBPR participants relate to the population as a whole.

METHODS

GoodNEWS participants in 20 African-American churches in Dallas, Texas were compared with age/sex-matched African-Americans in the Dallas Heart Study (DHS), a probability-based sample of Dallas County residents. DHS characteristics were sample-weight adjusted to represent the Dallas County population.

RESULTS

Despite having more education (college education: 75 versus 51%, P< 0.0001), GoodNEWS participants were more obese (mean body mass index: 34 versus 31 kg/m(2), P< 0.001) and had more diabetes (23 versus 12%, P< 0.001) and hyperlipidemia (53 versus 14%, P< 0.001) compared with African-Americans in Dallas County. GoodNEWS participants had higher rates of treatment and control of most CVRFs (treated hyperlipidemia: 95 versus 64%, P< 0.001; controlled diabetes: 95 versus 21%, P< 0.001; controlled hypertension: 70 versus 52%, P= 0.003), were more physically active (233 versus 177 metabolic equivalent units-min/week, P< 0.0001) and less likely to smoke (10 versus 30%, P< 0.001).

CONCLUSIONS

Compared with African-Americans in Dallas County, CBPR participants in church congregations were more educated, physically active and had more treatment and control of most CVRFs. Surprisingly, this motivated population had a greater obesity burden, identifying them as a prime target for CBPR-focused obesity treatment.

Dietary approaches to hypertension: a call to pharmacists to promote lifestyle changes

OBJECTIVES

To describe guideline updates regarding a dietary approach to preventing or treating hypertension and to encourage pharmacists to provide education to patients on the Dietary Approaches to Stop Hypertension (DASH) diet and reducing dietary sodium intake.

DATA SOURCES

Abstracts and published articles identified by searching Medline (January 2001 to July 2011) and International Pharmaceutical Abstracts (January 2001 to July 2011) using the terms hypertension, cardiovascular risk, risk reduction behavior, health behavior, community pharmacy services, counseling, diet, and sodium-restricted diet, as well as reports from the Institute of Medicine and Dietary Guidelines for Americans 2010.

DATA SYNTHESIS

In the Dietary Guidelines for Americans 2010, the recommended daily dietary sodium intakes for individuals with hypertension, chronic kidney disease, and diabetes was reduced to less than 1,500 mg per day. All other healthy individuals are recommended to achieve dietary sodium intakes of less than 2,300 mg per day. Americans are consuming excessive amounts of dietary sodium in the form of processed foods, which poses a barrier to blood pressure control. Pharmacists should recommend the DASH diet as a way to reduce intake of dietary sodium and use available nutrition resources found on the ChooseMyPlate.gov and Food and Drug Administration websites. Pharmacists should integrate approaches using behavioral and motivational strategies to provide education that is culturally sensitive and appeals to individuals with marginal health literacy.

CONCLUSION

Community and ambulatory practice pharmacists, as well as collaborative practice models between pharmacists and physicians, should optimize medication management and incorporate lifestyle interventions that reduce dietary sodium intake as part of a comprehensive approach to improve hypertension outcomes.

Barriers to lifestyle risk factor assessment and management in hypertension: a qualitative study of Australian general practitioners

Hypertension is a leading cause of mortality and disease burden worldwide, yet its management remains suboptimal. Identification and management of lifestyle risk factors should be a clinical priority in all patients because of the beneficial effects of lifestyle intervention on blood pressure. The objective of this qualitative focus group study was to identify barriers to lifestyle management in hypertension in Australian general practice. Purposeful sampling was used to select large group practices. Six focus groups (n=30) were audio recorded and transcribed. An iterative thematic analysis was conducted. Overall participants felt they had the required knowledge to provide broad lifestyle advice. However, cynicism dominated due to an overwhelming lack of success in practice. Patient reluctance and ambivalence were identified as major barriers but participants were willing to share the responsibility. Other barriers included time, reduced access to allied health and broader determinants of health. General practitioners need to be empowered to allow continuation of valuable lifestyle advice and counselling. The results emphasise the importance of ongoing lifestyle assessment and tailoring of management to the complex interplay of factors that impact on a patient's ability to adopt and maintain lifestyle change. System issues need to be addressed to provide better streamlined care.

Powering Adherence to Physical Activity by Changing Self-Regulatory Skills and Beliefs: Are Kinesiologists Ready to Counsel?

There are multiple avenues to gain health promoting and disease preventing benefits of physical activity (PA) but nonadherence makes health benefits short-lived. Gains obtained through structured exercise training and therapy quickly decay once participants leave programs. Scientific position statements underscore cognitive-behavioral strategies (CBS) as an essential intervention component to increase and maintain PA and recommend transfer of CBS knowledge to practice. Our review of reviews indicates high quality PA interventions involving CBS consistently demonstrate medium effect sizes. Kinesiologists are the human resource capacity to translate this knowledge. Building capacity to implement CBS knowledge is potentially large given North American kinesiology programs and American College of Sports Medicine and Canadian Society for Exercise Physiology certification routes. Yet CBS training of kinesiologists by universities and organizations is minimal. Immediate change in CBS training and practice is needed. Professional organizations/institutions can either be leaders in developing human resources or part of the problem should they fail to address the challenge of CBS training.

Increasing physical activity of high intensity to reduce the prevalence of chronic diseases and improve public health

High incidence and prevalence of chronic diseases, increasing obesity and inactivity as well as rising health expenditure represent a set of developments that cannot be considered sustainable, and will have dire long-term consequences given the increasing proportion of elderly people in our society. Based on a review of the experiences from previous large scale population-based prevention programs and the documented effects of increased physical activity and cardiorespiratory fitness on chronic diseases and its risk factors, we argue that increased physical activity, especially vigorous physical activity, is a major way to reduce the prevalence of chronic diseases and improve public health. We conclude that a coordinated population-based intervention program for improved health through increased physical activity in the entire population, with a special focus on high intensity exercise, urgently needs to be implemented nationally and internationally.

Physical activity and nutrition behavioural outcomes of a home-based intervention program for seniors: a randomized controlled trial

Background

This intervention aimed to ascertain whether a low-cost, accessible, physical activity and nutrition program could improve physical activity and nutrition behaviours of insufficiently active 60–70 year olds residing in Perth, Australia.

Methods

A 6-month home-based randomised controlled trial was conducted on 478 older adults (intervention, n = 248; control, n = 230) of low to medium socioeconomic status. Both intervention and control groups completed postal questionnaires at baseline and post-program, but only the intervention participants received project materials. A modified fat and fibre questionnaire measured nutritional behaviours, whereas physical activity was measured using the International Physical Activity Questionnaire. Generalised estimating equation models were used to assess the repeated outcomes over both time points.

Results

The final sample consisted of 176 intervention participants and 199 controls (response rate 78.5%) with complete data. After controlling for demographic and other confounding factors, the intervention group demonstrated increased participation in strength exercise (p < 0.001), walking (p = 0.029) and vigorous activity (p = 0.015), together with significant reduction in mean sitting time (p < 0.001) relative to controls. Improvements in nutritional behaviours for the intervention group were also evident in terms of fat avoidance (p < 0.001), fat intake (p = 0.021) and prevalence of frequent fruit intake (p = 0.008).

Conclusions

A minimal contact, low-cost and home-based physical activity program can positively influence seniors’ physical activity and nutrition behaviours.

Trial registration

anzctr.org.au Identifier: ACTRN12609000735257