Innovative approaches to comprehensive cardiovascular disease risk reduction in clinical and community-based settings

Lifestyle Risk Behaviors Among Stroke Survivors With and Without Diabetes

OBJECTIVE

History of stroke and diabetes increases risk for cardiometabolic disease, which can be mitigated through lifestyle management. To evaluate lifestyle risk behaviors among stroke survivors, we compared the prevalence of three lifestyle risk behaviors-physical inactivity, consuming one or less fruit and one or less vegetable daily, and overweight/obesity-between stroke survivors with and without diabetes.

DESIGN

Data from the 2013 and 2015 Behavioral Risk Factor Surveillance System were examined. Weighted and age-adjusted prevalence estimates as well as crude and adjusted odds ratios (adjusted for sociodemographic characteristics) were calculated to compare lifestyle risk behaviors between US stroke survivors with and without diabetes.

RESULTS

Prevalence and adjusted odds ratios for lifestyle risk behaviors were higher in respondents with diabetes compared with those without diabetes for consuming one or less fruit and one or less vegetable daily (58.8% vs. 53.7%, adjusted odds ratio = 1.14), physical inactivity (65.7% vs. 54.6%, adjusted odds ratio = 1.41), and overweight/obesity (87.2% vs. 63.1%, adjusted odds ratio = 2.42).

CONCLUSIONS

Prevalence of select lifestyle risk behaviors exceeds 50% in adults with stroke but is higher in adults with diabetes compared with adults without diabetes. Effective interventions, community programs, and healthcare policy are needed to promote lifestyle management in adults with stroke, particularly among those with diabetes.

Weight management telehealth intervention for overweight and obese rural cardiac rehabilitation participants: A randomised trial

AIMS AND OBJECTIVES

To determine whether a weight management intervention (WMI) plus cardiac rehabilitation (CR) compared to CR alone improves outcomes for overweight and obese cardiac revascularisation patients.

BACKGROUND

Despite participating in cardiac rehabilitation (CR), few cardiac patients lose enough weight to achieve clinically significant cardiovascular disease risk reduction.

DESIGN

A randomised controlled design was used with measurements at baseline, 4 and 6 months, guided by the CONSORT checklist, see Supporting Information File S1. Adults who had undergone either coronary artery bypass surgery (CABS) or percutaneous coronary intervention (PCI) and participated in a rural CR programmes were recruited. Subjects were randomised to a 12-week telehealth WMI or control group. The primary outcome was weight loss. Secondary outcomes included physical activity, patient activation, perceived self-efficacy and use of weight management behaviours.

RESULTS

A total of 43 subjects participated, with a mean age of 63 (±9.3) years. The WMI group had significantly more weight loss averaged across the 4 and 6 months of 13.8 (±2.8) pounds compared to the control group [mean = 7.8 (±2.2) pounds]. There were no significant differences in physical activity (activity counts or daily minutes in moderate or more intense activity). The WMI group had significantly higher levels of patient activation. They also had significantly higher total scores on the Diet and Exercise Self-Management survey, and subscales that included self-efficacy for specific eating habits and managing diet behaviour.

CONCLUSIONS

Findings demonstrated the usefulness and feasibility of using telehealth delivery of the WMI for cardiac rehabilitation participants in rural communities to improve weight management outcomes.

RELEVANCE TO PRACTICE

Study findings underscore the opportunity to further improve weight loss of overweight and obese cardiac participants using a weight management intervention to augment CR participation.

Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking?

Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20-1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization.

Lifestyle Modification for Secondary Stroke Prevention

Of nearly 800 000 strokes that occur annually, 23% are recurrent events. Risk for disability and mortality is higher following a recurrent stroke than following a first-time stroke, which makes secondary stroke prevention a priority. Many risk factors for stroke are modifiable and amenable to improvement through lifestyle modification. Lifestyle modification can be difficult for people with stroke, however, in part because of stroke-related physical and cognitive deficits. Despite these challenges, risk factor management through lifestyle modification is important. This article reviews the multiple cardiovascular and metabolic benefits associated with the modification of several lifestyle behaviors: diet, physical activity, smoking cessation, and alcohol consumption. Health behavior theories and existing lifestyle intervention programs are also reviewed to identify important behavioral and cognitive skills that can be used to facilitate modification of health behaviors, and practical skills and suggestions for health care providers are provided.

Multiple Risk Factor Counseling to Promote Heart-healthy Lifestyles in the Chest Pain Observation Unit: Pilot Randomized Controlled Trial

OBJECTIVE

Admission to the chest pain observation unit (CPOU) may be an advantageous time for patients to consider heart-healthy lifestyle changes while undergoing diagnostic evaluation to rule out myocardial ischemia. The aim of this pragmatic trial was to assess the effectiveness of a multiple risk factor intervention in changing CPOU patients' health beliefs and readiness to change health behaviors. A secondary aim was to obtain preliminary estimates of the intervention's effect on diet, physical activity, and smoking.

METHODS

We conducted a pilot randomized controlled trial of a moderate-intensity counseling intervention that aimed to build motivation to change and problem-solving skills in 140 adult patients with at least one modifiable cardiovascular risk factor (CRF) who were admitted to the CPOU of an academic emergency department (ED) with symptoms of possible acute coronary syndrome. Study patients were randomly assigned to full counseling (face-to-face cardiovascular risk assessment and personalized counseling on nutrition, physical activity, and smoking cessation in the ED, plus two telephone follow-up sessions) or minimal counseling (brief instruction [<5 minutes] on benefits of modifying cardiovascular risk factors) by a cardiac rehabilitation specialist. We measured Health Belief Model constructs for ischemic heart disease, stage of change, and self-reported CRF-related behaviors (diet, exercise, and smoking) during 6-month follow-up using previously validated measures. We used linear mixed models and logistic regression (with generalized estimating equations) to compare continuous and dichotomous behavioral outcomes across treatment arms, respectively.

RESULTS

Approximately 20% more patients in the full counseling arm reported having received counseling on diet and physical activity during CPOU admission, compared to the minimal counseling arm; a similar proportion of patients in both counseling arms reported having received advice or assistance in quitting smoking. There were no significant differences between treatment arms for any cardiovascular health beliefs, readiness to change, or CRF-related behaviors during longitudinal follow-up. In secondary analyses in both treatment arms combined, however, patients showed significant differences between follow-up and baseline measurements: increases in the perceived benefits of improving CRF-related behaviors (27.7 vs. 26.6 on a scale from 7 to 35, p = 0.0001) and increased readiness to change dietary behavior and physical activity during follow-up-intake of saturated fat (83% vs. 49%), readiness to change fruit and vegetable consumption (83% vs 56%), and readiness to perform regular exercise (34% vs. 14%) at 6 months and baseline, respectively (p < 0.0001 for all comparisons in both treatment arms combined).

CONCLUSIONS

A multiple risk factor intervention that focused on increasing motivation to change and problem-solving skills did not significantly improve behavioral outcomes, compared to minimal counseling. Patients admitted to the CPOU demonstrated sustained changes in several cardiovascular health beliefs and risk-related behaviors during follow-up; this provides further evidence that the CPOU visit is a "teachable moment" for cardiovascular risk reduction. Future studies should evaluate the effectiveness of ED-initiated counseling interventions to engage patients in changing cardiovascular risk behaviors, in coordination with primary care.

Clinical Effectiveness of Lifestyle Health Coaching: Case Study of an Evidence-Based Program

We have developed, tested, and successfully implemented an affordable, evidence-based, technology-enabled, data-driven, outcomes-oriented, comprehensive lifestyle health coaching (LHC) program. The LHC program has been used primarily to provide services to employees of larger employers (ie, with at least 3000 employees) but has also been implemented in a variety of other settings, including hospitals, cardiac rehabilitation centers, physician practices, and as part of multicenter clinical trials. The program is delivered mainly using the telephone and Internet. Health coaches are guided by a Web-based participant management and tracking system. Lifestyle management interventions are based on several behavior change models and strategies, especially adult learning theory, social learning theory, the stages of change model, single concept learning theory, and motivational interviewing. The program is administered by nonphysician health professionals whose services are integrated with the care provided by participants' physicians. Outcomes data from published studies, including randomized clinical trials and independent third-party conducted research, have documented the clinical effectiveness of this evidence-based approach in terms of modification of multiple risk factors in healthy persons as well as those with certain common chronic diseases.

Multicenter Study of Temporal Trends in the Achievement of Atherosclerotic Cardiovascular Disease Risk Factor Goals During Cardiac Rehabilitation

PURPOSE

Secondary prevention risk factor goals have been established by the American Heart Association/American College of Cardiology, and the American Heart Association has further delineated ideal cardiovascular health metrics. We evaluated risk factor goal achievement during early-outpatient cardiac rehabilitation (CR) and temporal trends in risk factor control.

METHODS

Patients completed assessments on entry into and exit from CR at 35 centers between 2000 and 2009 and were categorized into 3 cohorts: entire (N = 12 984), 2000-2004 (n = 5468), and 2005-2009 (n = 7516) cohorts.

RESULTS

Improvements occurred in multiple risk factors during CR. For the entire cohort, the percentages of patients at goal at CR completion ranged from 95.5% for smoking to 21.9% for body mass index (BMI) of <25.0 kg/m. Compared with 2000-2004, the percentage of the 2005-2009 cohort at goal was higher (P < .001) for blood pressure, low-density lipoprotein cholesterol, and physical activity, lower (P = .005) for BMI, and not significantly different (P > .05) for fasting glucose and smoking. At CR completion, of those in the entire, 2000-2004, and 2005-2009 cohorts, 4.4%, 3.9%, and 4.8% (P = .219 vs 2000-2004), respectively, had all biomarkers at the goal for ideal cardiovascular health and, of those with atherosclerotic cardiovascular disease, 70.8%, 71.5%, and 70.3% (P = .165 vs 2000-2004), respectively, were receiving statins.

CONCLUSIONS

The percentage of patients at goal at CR completion increased for some, but not all, risk factors during 2005-2009 versus 2000-2004. Despite the benefits of CR, risk factor profiles are often suboptimal after CR. There remains room for improvement in risk factor management during CR and a need for continued intervention thereafter.

Building a Footbridge From Research to Practice in Cardiovascular Risk Reduction

As Rippe, Angelopoulos, and Zukley noted in their State-of-the-Art Review, empirically supported lifestyle modification strategies offer numerous advantages over other modalities for reducing cardiovascular risks. Yet, despite compelling evidence for their implementation, the translation of lifestyle interventions from research to practice has been challenging. Their review prompts discussion of several especially thorny barriers including the persistent tensions between (1) research and practice, (2) main effects and mediators, (3) single and multifactor approaches to risk management, and (4) primary care and communitybased systems of health delivery.

The Cooperative Lifestyle Intervention Program-II (CLIP-II): design and methods

A complication of cardiovascular disease (CVD) and the metabolic syndrome (MetS) among older adults is loss of mobility. The American Heart Association has identified weight management as a core component of secondary prevention programs for CVD and is an important risk factor for physical disability. The American Society for Nutrition and the Obesity Society have highlighted the need for long-term randomized clinical trials to evaluate the independent and additive effects of diet-induced weight loss (WL) and physical activity in older persons on outcomes such as mobility, muscle function, and obesity related diseases. Here we describe the rationale, design, and methods of a translational study, the Cooperative Lifestyle Intervention Program-II (CLIP-II). CLIP-II will randomize 252 obese, older adults with CVD or MetS to a weight loss only treatment (WL), aerobic exercise training (AT)+WL, or resistance exercise training (RT)+WL for 18 months. The dual primary outcomes are mobility and knee extensor strength. The interventions will be delivered by YMCA community partners with our staff as trainers and advisers. This study will provide the first large scale trial to evaluate the effects of diet-induced WL on mobility in obese, older adults with CVD or MetS as compared to WL combined with two different modes of physical activity (AT and RT). Because uncertainty exists about the best approach for promoting WL in older adults due to concerns with the loss of lean mass, the design also permits a contrast between AT+WL and RT+WL on muscle strength.

Effect of exercise-based cardiac rehabilitation on multiple atherosclerotic risk factors in patients taking antidepressant medication

Antidepressants might increase compliance with cardiovascular disease risk reduction interventions. However, antidepressants have been linked to deleterious metabolic effects. In the present multicenter study, we sought to determine whether patients who take antidepressants derive the expected benefits from cardiac rehabilitation in terms of improvements in multiple atherosclerotic risk factors. A cohort of 26,957 patients who had completed a baseline assessment before participating in an exercise-based cardiac rehabilitation program constituted the study population. The patients were stratified into 3 cohorts (i.e., nondepressed, depressed unmedicated, and depressed medicated) at baseline according to a self-reported history of depression and the current use of antidepressants. Risk factors were assessed at baseline and after ∼12 weeks of program participation. A self-reported history of depression was present at baseline in 5,172 patients (19.2%). Of these patients, 2,147 (41.5%) were taking antidepressants. Patients in the nondepressed cohort (49.4% completion) were more likely (p <0.001) to complete the exit assessment than patients in the depressed unmedicated (44.5% completion) or depressed medicated (43.5% completion) cohorts. Patients in all 3 cohorts who completed the exit assessment showed significant improvement in multiple risk factors. Moreover, the magnitude of improvement in blood pressure, serum lipids and lipoproteins, fasting glucose, weight, and body mass index was similar (p >0.05) in patients taking antidepressants and those who were not. In conclusion, our study is the first to show that antidepressants do not offset the average magnitude of improvement in multiple atherosclerotic risk factors that occurs with completion of a cardiac rehabilitation program.

Effect of comprehensive therapeutic lifestyle changes on prehypertension

Although national clinical guidelines promulgate therapeutic lifestyle changes (TLC) as a cornerstone in the management of prehypertension, there is a perceived ineffectiveness of TLC in the real world. In this study of 2,478 ethnically diverse (African Americans n = 448, Caucasians n = 1,881) men (n = 666) and women (n = 1,812) with prehypertension and no known atherosclerotic cardiovascular disease, diabetes mellitus, or chronic kidney disease, we evaluated the clinical effectiveness of TLC in normalizing blood pressure (BP) without antihypertensive medications. Subjects were evaluated at baseline and after an average of 6 months of participation in a community-based program of TLC. TLC included exercise training, nutrition, weight management, stress management, and smoking cessation interventions. Baseline BP (125 +/- 8/79 +/- 3 mm Hg) decreased by 6 +/- 12/3 +/- 3 mm Hg (p <or=0.001), with 952 subjects (38.4%) normalizing their BP (p <or=0.001). In subjects with a baseline systolic BP of 120 to 139 mm Hg (n = 2,082), systolic BP decreased by 7 +/- 12 mm Hg (p <or=0.001). In subjects with a baseline diastolic BP of 80 to 89 mm Hg (n = 1,504), diastolic BP decreased by 6 +/- 3 mm Hg (p <or=0.001). There were no racial differences in the magnitude of reduction in BP; however, women had greater BP reductions than men (p <or=0.001). Also, subjects with a baseline body mass index (BMI) <30 kg/m(2) had a greater reduction in BP than those with a BMI >or=30 kg/m(2). In conclusion, the present study adds to previous research by reporting on the effectiveness, rather than the efficacy, of TLC when administered in a real-world, community-based setting.

Managing abnormal blood lipids: a collaborative approach

Current data and guidelines recommend treating abnormal blood lipids (ABL) to goal. This is a complex process and requires involvement from various healthcare professionals with a wide range of expertise. The model of a multidisciplinary case management approach for patients with ABL is well documented and described. This collaborative approach encompasses primary and secondary prevention across the lifespan, incorporates nutritional and exercise management as a significant component, defines the importance and indications for pharmacological therapy, and emphasizes the importance of adherence. Use of this collaborative approach for the treatment of ABL ultimately will improve cardiovascular and cerebrovascular morbidity and mortality.

Effectiveness of therapeutic lifestyle changes in patients with hypertension, hyperlipidemia, and/or hyperglycemia

In this prospective study of 2,390 ethnically diverse men and women, we evaluated the clinical effectiveness of 12 weeks of participation in a community-based lifestyle management program in helping patients who had hypertension, hyperlipidemia, and/or impaired fasting glucose or diabetes mellitus achieve goal risk factor levels without using pharmacotherapeutic agents. Although further research is warranted, the findings clearly show that many patients who have conventional risk factors for coronary heart disease can achieve goal levels without medications within 12 weeks of initiating therapeutic lifestyle changes and refute the notion that intensive lifestyle intervention is not worth the effort.

Promoting Prevention

Preventive therapies have been shown to reduce morbidity and mortality from cardiovascular disease. However, health care providers are not addressing prevention and not treating patients according to evidence-based guidelines. Reasons frequently cited for not delivering health promotion/disease prevention oriented care is lack of training or skills to provide counseling, and a lack of confidence in health care provider skills. This article outlines the skills and attributes considered essential for a health care provider to promote behavioral change and risk reduction. The skills and attributes of the health care provider, such as expertise and knowledge, skills for assessing readiness for behavior change, relationship building skills, and skill in considering the patient's attitudes and beliefs about the disease or treatment are discussed. Principles of communication to guide the patient-provider encounter, key behavioral change strategies, and use of technology are reviewed and resources available to support prevention goals are presented.

Methodologic advances and ongoing challenges in designing community-based health promotion programs

Community intervention trials continue to attract researchers as potential ways to achieve widespread, long-term change in health behaviors. The first generations of community studies were somewhat unsophisticated in design and analysis, and their promise may have been overstated. As design and analysis issues were better defined, as secular trends caught up with the behaviors that researchers were trying to change, or as other unknown variables affected community studies, small effects of interventions were observed in community trials. Discussions were held in professional meetings and reported in the literature: Should community trials be discontinued? In general, the answer was a qualified no. In this paper, we briefly review some of the many advances made in community intervention trials, and address in more detail the challenges ahead.

Effects of a contemporary, exercise-based rehabilitation and cardiovascular risk-reduction program on coronary patients with abnormal baseline risk factors

Phase II cardiac rehabilitation programs are associated with improvements in exercise tolerance, coronary risk factors, and psychosocial well-being. Nevertheless, previous reports have generally evaluated the global effectiveness of these programs (ie, on all subjects, collectively), which may serve to camouflage or attenuate the impact of these interventions on specific patient subsets. In this study, we investigated the effectiveness of a contemporary, exercise-based cardiac rehabilitation program that included a cardiovascular risk-reduction intervention, using a computerized database on 117 patients (average age, 66.5 years; 68% men; 96% white) who completed pre-phase II and post-phase II evaluations. Exercise training involved three 45- to 60-min sessions per week at minimum of 40 to 50% to a maximum of 75% oxygen uptake for 6 to 8 weeks. The effectiveness of the exercise training program was substantiated by significant (p <or= 0.05) reductions in heart rate (- 8 beats/min), systolic BP (- 11 mm Hg), and rating of perceived exertion (- 2, 6 to 20 scale) at a standard submaximal workload. Initial and follow-up ratings of overall health were improved: excellent (2.6 to 4.3%) and very good (20.7 to 35.7%). Average changes (p <or= 0.05 unless otherwise indicated) for all participants and those with abnormal baseline risk factors were as follows: systolic BP (- 4 mm Hg and - 16 mm Hg); diastolic BP (- 5 mm Hg and - 18 mm Hg); total cholesterol (- 19 mg/dL and - 75 mg/dL); low-density lipoprotein cholesterol (- 17 mg/dL and - 61 mg/dL); high-density lipoprotein cholesterol (- 1 mg/dL [not significant] and + 11 mg/dL); and triglycerides (- 5 mg/dL [not significant] and - 82 mg/dL), respectively. The present findings suggest that a positive correlation generally characterizes the change in coronary risk factors subsequent to a contemporary phase II cardiac rehabilitation program. Patients with the worst coronary risk factor profiles at baseline demonstrated the greatest improvements.

Effectiveness of three models for comprehensive cardiovascular disease risk reduction

Cost and accessibility contribute to low participation rates in phase 2 cardiac rehabilitation programs in the United States. In this study, we compared the clinical effectiveness of 2 less costly and potentially more accessible approaches to cardiovascular risk reduction with that of a contemporary phase 2 cardiac rehabilitation program. Low- or moderate-risk patients (n = 155) with coronary artery disease (CAD) were randomly assigned to 12 weeks of participation in a contemporary phase 2 cardiac rehabilitation program (n = 52), a physician supervised, nurse-case-managed cardiovascular risk reduction program (n = 54), or a community-based cardiovascular risk reduction program administered by exercise physiologists guided by a computerized participant management system based on national clinical guidelines (n = 49). In all, 142 patients (91.6%) completed testing at baseline and after 12 weeks of intervention. For patients with abnormal (i.e., not at the goal level) baseline values, statistically significant (p < or =0.05) improvements were observed with all 3 interventions for multiple CAD risk factors. No statistically significant risk factor differences were observed among the 3 programs. For patients with a baseline maximal oxygen uptake < 7 metabolic equivalents, cardiorespiratory fitness increased to a greater degree in patients in the cardiac rehabilitation program and the community-based program versus the physician-supervised, nurse- case-managed program. These data have important implications for cost containment and increasing accessibility to clinically effective comprehensive cardiovascular risk reduction services in low- or moderate-risk patients with CAD.