Get a Life(style): About 80% of CVD involves choices; getting patients to choose wisely
Cover Story | By Debra L. Beck
Cardiovascular disease (CVD) is primarily treated with medications, those that lower lipid levels and others that reduce the strain on a sub-optimally functioning heart. What about using meditation (with a t, not a c) or yoga to reduce the heart’s workload? Or using good old fashioned exercise to restore lipid balance, reduce blood pressure, lower BMI, and increase self-confidence, happiness, and general health behaviors? We know activity boosts brain power, but did you know physical inactivity is a brain drain?
CVD is treated with interventions—surgical and percutaneous—aimed at enhancing blood flow or repairing failing heart parts. But what about intervening in dysfunctional lifestyles and communities to enhance interpersonal perfusion, work flow, traffic flow, and the flow of conversation between good friends?
Impossible, right? These lifestyle fixes are in the realm of behavioral cardiology, an emerging field seeking to bridge the divide between heart and mind via the myriad behavioral and psychosocial factors associated with health – or lack, thereof.
The latest data come with the January 5, 2015 issue of the JACC. Andrea K. Chomistek, ScD, and colleagues, from the School of Public Health, Indiana University, Bloomington, used data on 88,940 participants in the Nurses’ Health Study II (NHS2) who were between the ages of 27 and 44 at baseline (in 1999) and had no history of cancer, CVD, or diabetes.1 The researchers considered six lifestyle factors that defined healthy living: smoking (er...none!), diet (top 40% of the distribution of the alternative healthy eating index score), physical activity (at least 2.5 hrs/wk), television watching (<7 hrs/wk), body mass index (<25 kg/m2), and alcohol consumption (about 1 drink/day as suggested for women by current guidelines).
During 20 years of follow-up, there were 456 incident CVD cases and 31,691 reports of a physician’s diagnosis of one or more clinical CVD risk factors—diabetes (n = 2,749 women), hypertension (n = 16,978), and hypercholesterolemia (n = 23,971). No surprise, those women adhering to all six healthy lifestyle factors had less risk for CVD than those adhering to none; 92% less, in fact.
In multivariate-adjusted models, non-smoking, healthy BMI, exercise, and healthy diet were all independently and significantly associated with lower CHD risk; for alcohol consumption a J-shaped relationship was noted and as for TV watching – well, maybe it’s not great for the brain, but it was not significantly associated with CHD after adjusting for other factors.
The problem, as you might guess: only 4.6% of the study population fell into the optimal category for all 6 lifestyle factors.
Primordial Sea Change?
“This study is timely given recent indication that the CHD mortality rate in women aged 35-44 years may not be declining as it is in other groups,” said Dr. Chomistek. It also strongly hints that primordial prevention through healthy lifestyle might go far in addressing the economic burden of the medical management of CVD and its risk factors.
This NHS2 analysis may be the first to look at the association between lifestyle factors and the risk of both clinical CVD risk factors and incident CVD, but the recent literature is replete with evidence of the cardiovascular benefits of good health, and the converse.
By the way, men don’t fare any better. Agneta Akesson, PhD, and colleagues in the nutritional epidemiology department at the Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden, published a population-based prospective cohort study this past September, also in JACC, showing similar findings in men.
In the Akesson study, the researchers looked at five lifestyle factors: healthy diet, moderate alcohol consumption, smoking, physical activity, and abdominal adiposity, in 20,721 men between the ages of 45 and 79 and followed them for a mean of 11 years. The population attributable risk estimated for those following all five health behaviors compared with the remaining men in the study population was 79%, suggesting that about four of five first coronary events could potentially have been averted if all men had followed low-risk practices.
A whopping 1%, or 212 out of 20,721 men, practiced all five health behaviors; from which, three had myocardial infarctions. This low prevalence of “ideal” cardiovascular health has been documented in U.S. national samples.3,4 However, and importantly, the issue is not all or nothing: each behavior, by itself, reduced the risk for MI. For example, eating a diet rich in beneficial foods such as fruits, vegetables, nuts, reduced-fat dairy, and whole grains was associated with nearly 20% lower risk versus those who practiced none of the healthy behaviors.
If just informing people of the dangers of, say, eating greasy fast foods for breakfast, lunch, and dinner were an effective means of behavioral change, then this issue would have become a non-issue long ago.
“All that remains is the task of successfully convincing young adults not to smoke, to exercise more, and to eat and drink prudently,” wrote Donna K. Arnett, MSPH, PhD, from the School of Public Health at the University of Alabama, Birmingham, in an editorial accompanying the NHS II results.5 Dr. Arnett went on to say: “The irony of that last statement is somewhat mitigated by the most encouraging aspect of Chomistek et al—its very appearance in a journal with JACC’s stature and readership. If there’s any hope in successfully convincing young women (and everyone else) not to smoke, to exercise more, and to eat and drink prudently, it lies in creating a world where doing those things is the default option,” said Dr. Arnett. And this represents not a shift, but a sea change.
Enter Behavioral Cardiology
Behavioral cardiology looks at the links between various behavioral and psychosocial factors and the pathogenesis and progression of coronary heart disease (CHD).
“What governs our health behaviors—whether it’s eating well or finding time to exercise—is the larger context of how we’re feeling emotionally, the quality of our thinking, whether we feel a lot of stress, whether we’re feeling lonely or we feel like we have an active social life, and our overall sense of purpose,” said Alan Rozanski, MD, in an interview with CardioSource WorldNews. Dr. Rozanski is the chief of cardiology at Mount Sinai St. Lukes and Roosevelt Hospital Center, New York and has written three reviews on behavioral cardiology between 1999 and now.
He divides the behavioral risk factors for CHD into five broad categories: physical health behaviors, negative emotions and mental mindsets, chronic stress, social isolation and poor social support, and lack of sense of purpose.
While physical activity and diet or weight management are generally classified as “conventional” risk factors, he objects to placing an “artificial divide” between exercise and eating and other behavioral and psychosocial risk factors. “Overcoming this divide could lead to the development of more integrated, effective behavioral interventions,” said Dr. Rozanksi.
“Negative psychosocial factors promote illness by fostering negative health behaviors and by their direct pathophysiological effects,” he said. “These effects can vary according to the type of psychosocial stress, but as a group they include induction of autonomic dysfunction, heightened cardiovascular reactivity, insulin resistances, central obesity, increased risk for hypertension, endothelial and platelet dysfunction, and unfavorable alterations in brain plasticity and cognitive function.”
Many if not most of the psychosocial risk factors are interlinked and replete with both positive and negative feedback loops that may offer opportunities to broadly affect an individual’s overall behavioral milieu. For example, treating depression can improve health behaviors, lessen stress, improve social performance, and increase sense of purpose. Along the same lines, exercise reduces heart rate, blood pressure, and the cortisol and glucose responses to psychosocial stress, as well as buffering the relationship between depression and inflammation.
“Over the last 30 years, a remarkable evidence base has developed showing that two risk factors specifically—depression and social isolation—are linked to a higher risk for coronary events and reduced longevity without treatment,” said Dr. Rozanski, but cardiologists are used to guideline-driven treatment, not the high degree of clinical judgment needed to treat behavioral risk factors.
Certainly, there is no “one size fits all” fixes in the behavioral domain. “Whereas many professionals are currently trained to provide specialized expertise in such areas as fitness instruction, dietary counseling, sleep hygiene, rest and relaxation techniques, and psychological counseling, few are trained in integrating these services,” wrote Dr. Rozanski. “The development of such expertise would aid the growth of behavioral cardiology as a new, distinct subspecialty within cardiology.”
A Campaign that Worked
We need to do to our crummy lifestyles what we did to smoking, suggested Dr. Rozanski. In the 1960s, up to 50% of adult American men were smoking. Today, smoking rates have dropped by about half. How did we accomplish such progress in what is generally considered a very hard behavior to change?
“It was multifaceted—we called awareness to it, the medical societies got on top of it, we taxed smoking, banned it in public places, put age limits on buying cigarettes, worked to prevent kids from starting the habit—all of these different things helped,” said Dr. Rozanski.
The same approach needs to be taken with improving lifestyle behaviors. Individuals, communities, professional societies, even public policy can help.
He also feels that programs need to be developed, likely on the hospital level, that employ specialists to attend to all the different lifestyle factors—nutritional counseling, exercise specialists, stress management, sleep hygiene, and treatment for depression, if needed.
“Doctors will pay attention to this and assist if there are programs for them to refer the patients to,” said Dr. Rozanski. “You can’t expect the cardiologists to become someone who is going to advocate for their patients to manage their time better, get more rest, or find better social support, but if there are effective programs available, they will screen for these problems and refer patients.”
If this sounds a bit like cardiac rehab, that’s because it is. Cardiac rehab is a program that works, said Dr. Rozanksi, but it’s too expensive to be applied to the numbers who need lifestyle intervention. His suggestion is to employ group-based interventions to keep costs down. “It’s like we need cardiac rehab today that is expansive, inclusive, and inexpensive,” he said.
Nathan Wong, PhD, a co-editor of Preventive Cardiology: A Companion to Braunwald’s Heart Disease and the director of the Heart Disease Prevention Program at University of California, Irvine agrees that while cardiovascular healthcare providers have a primary responsibility to ensure lifestyle issues are addressed in their patients, we also need government and community involvement to promote healthier lifestyles for the population in general.
He told CSWN, “For example, we should be working with our local, state, and national governmental officials to sponsor and pass legislation aimed to reduce sodium content and eliminate trans-fats in processed foods, as well as to restrict or eliminate cigarette smoking in all public places.”
This combination of approaches will have a “dramatic impact” on the cardiovascular health of the nation. While there is much to be gained from better work environments, and community development that promotes active and outdoor living, at the end of the day, it’s the choices people make in their kitchens and lives that can ultimately make the biggest different in CVD incidence going forward.
Get Moving, the App
Wearable sensors, smartphones with accelerometers, apps—these are the tools of tomorrow (and today) that may turn the tide of sedentary behavior that has swept the Western world, according to Seth Martin, MD, a clinician and research fellow at Johns Hopkins University’s Ciccarone Center for Preventive Cardiology.
“Part of the reason I love focusing on physical activity is because it seems like this cornerstone habit that helps so many things,” said Dr. Martin. “There is some literature showing that more active people are able to quit smoking more successfully, have fewer urges to smoke, their mood is better, obviously they lose weight and improve cardiovascular health—it just seems so central to so many things.”
People who are physically active have lower risk for heart disease, stroke, type 2 diabetes, depression, and some cancers with associated dose-dependent reductions in cardiovascular and all-cause mortality. However, most U.S. adults do not meet CDC physical activity guidelines. And it’s looking more and more that lack of exercise—and not a tendency to eat too much—may explain why an increasing number of Americans are obese. Researchers analyzed U.S. government data from the last 20 years and found that the number of women who reported no physical activity rose from about 19% in 1994 to nearly 52% in 2010. For men, the change was from 11% to about 43%. At the same time, calorie intake among adults remained steady.6
Because apps and wearable sensors are so new, there is very little science supporting their effectiveness. However, one of the most popular uses of smartphone technology is to simply use the phone as a pedometer, and tracking steps improves activity levels. In 2007, a high profile review published in JAMA linked pedometer use with significant increases in physical activity and significant decreases in BMI and blood pressure.7
“However, there were some key caveats given in the paper,” said Dr. Martin, “the first of which was that to see that effect, it was contingent on participants having a step goal and the second was that the participants who kept step diaries were more successful at increasing their steps.”
Of course, using smartphone technology obviates the need to manually log steps, and given that 90% of adults in the US now use a mobile phone—and 58% have smartphones—mobile health technologies offer an easy means of improving health behaviors in the general population.
To better understand the potential of mobile technology to get folks moving, Dr. Martin and colleagues at Johns Hopkins conducted mActive, a blinded, randomized mobile health activity trial that used an activity tracker combined with personalized, health coaching via “smart” text messages.
In order to maintain blinding, the researchers gave cardiology patients a wearable digital tracker (the Fitbug Orb) that doesn’t show the participants’ steps on the device. One group remained blinded to their activity, a second group was unblinded to the numeric physical activity feedback information captured by the trackers, and a third group saw their activity data and received text messages.
The main results of the trial will be presented in the Spring, but Dr. Martin and colleagues have presented a few posters on their study showing that the trial was a recruitment success in that nearly all eligible participants (with equal proportions of women and men) opted to participate and that the mobile/electronic aspect of the tracking offered nearly complete data capture (a problem in past trials that relied on patients keeping step diaries). Also, the platform on which the trial ran is fully scalable to large randomized controlled trials, said Dr. Martin.
“It’s exciting because this could be a totally new era of research,” said Dr. Martin. “It’s more convenient and cheaper than things we’ve tried in the past.”
The question of long-term adherence hasn’t been answered yet, he noted. “There is some consumer research that indicated that for most people who buy these devices, after a year they’re sitting on the counter not being used, so part of the challenge will be to keep people engaged.”
- Chomistek AK, Chiuve SE, Eliassen AH, Mukamal KJ, et al. J Am Coll Cardiol 2015;65:43-51.
- Akesson A, Larsson SC, Discacciati A, Wolk A. J Am Coll Cardiol 2014;64:1299-306.
- Ford ES, Greenlund KJ, Hong Y. Circulation 2012; 125: 987-95
- Yang W, Cogswell ME, Flanders WD, et al. JAMA 2012;307:1273-83.
- Arnett DK. J Am Coll Cardiol 2015;65:52-4.
- Ladabaum U, et al. Am J Med 2014;127:717-27.
- Bravata DM, Smith-Spangler C, Sundaram V, et al. JAMA 2007; 298: 2296-304.
2014 in Review
What a year for lifestyle researchers! Assuming they did not stress too much working hard on their projects, the results should encourage them (and us) to think more about some of these issues.
Maybe They Can’t Remember What to Eat
The same bad habits that lead to heart disease contribute to learning and memory problems, too. The good news from a study of almost 18,000 middle-age Americans: Intermediate health risk profiles were just as good as excellent CV health risk. In other words, you did not have to be perfect; you just had to do better than the people with the worst cardiovascular health scores, who were almost twice as likely to develop cognitive impairment during a 4-year follow-up.
Thacker EL, et al. J Am Heart Assoc. June 2014.
A Policy of Lowering Cholesterol
We know what’s healthy and what’s less so in food choices. A change in the edible oil import policy from palm to soybean oil rewarded the people of the small island of Mauritius with a 0.8 mmol/L reduction in total cholesterol at no cost and without the need to medicate the whole population with statins. Such an approach would require political will that is currently lacking in most of the world, but it does underscore that alternatives might be worth considering.
Dowse GK, et al. BMJ. 1995; 311: 1255–59.
Well, what we know about food choices does change a little over time, and maybe it’s time to let eggs out of the dog house. Health professionals routinely advise patients with coronary disease to restrict dietary cholesterol from eggs and other sources, but David Katz, MD, MPH and his colleagues at the Yale-Griffin Prevention Research Center cite a lack of consistent evidence that dietary cholesterol actually impacts blood cholesterol levels. They compared the effects on cardiac risk factors of 6 weeks of daily intake of either two eggs, ½ cup of a commercially-available egg substitute, or a high-carbohydrate breakfast (choice of bagels, waffles, pancakes, or cereal), as part of an otherwise unrestricted diet. They found no evidence of adverse effects of daily egg ingestion on any cardiac risk factors in adults with CAD based on body weight, body mass index, blood pressure, serum lipids or endothelial function.
Yes, the study was funded by industry (the Egg Nutrition Center), but the message may be to look more broadly at diet rather than a single component.
Katz DL, et al. Am Heart J. 2015;169:162-9.
Call it a Style of Eating, Not a Diet: Speaking of food, 2014 was a banner year for Mediterranean-style eating.
Among 800 firefighters who most closely adhered to a Mediterranean-style eating pattern, 43% had less risk of weight gain and 35% had lower risk of being diagnosed with metabolic syndrome over 5 years of follow-up than peers whose diet was least like what could be called Mediterranean. (PLoS One, February 4th, 2014)
Investigators studied 6,000 men and women at risk for heart disease, two-thirds of whom already had metabolic syndrome at study entry. Compared to a low-fat diet, investigators found that a Mediterranean-style program with extra virgin olive oil was associated with a 35% greater likelihood of seeing a reversal in metabolic syndrome after 5 years. When supplemented with nuts (instead of the olive oil), a reduction in metabolic syndrome was 28% more likely among those eating the Mediterranean way rather than a low-fat diet. (CMAJ, October 14th)
Using the Nurse’s Health Study again, researchers found that a Mediterranean menu rich in whole grains, vegetables, fruits, legumes, nuts, fish and olive oil appears to be associated with longer telomere length, an indicator of slower aging. (BMJ, December 2nd)
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