Cover Story | By Alfred A. Bove, MD, PhD, Interim Editor-in-Chief, CardioSource WorldNews

This month, we devote the theme of CardioSource WorldNews to the concept of “lifestyle.” We should first try to define the term and what it means to our practice of cardiology. I like to go back to Berwick’s triple aim (www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx) for a health system: Better health, better health care, and lower cost. Better health gives our patients a more comfortable existence, free from debilitating illness, with longevity that reaches the life expectancy of at least the mid to upper 80’s, and is likely to go higher if we do our job right. Better health care relates to how we manage our patients, access to care, availability of therapies, and efficiency of care. The cost factor is obvious, but will improve if there is less illness, and if we learn to be more appropriate in our use of tests and procedures.

If we want to achieve better heath, we can look at the paper by Ford et al.¹ to find that, over a couple decades, about half of the improved mortality from cardiovascular disease (CVD) comes from “reduction in major risk factors” and about half from “evidence-based medical therapies.” If we want to make an impact on cardiovascular health, we need to address the risk factors, and continue to provide evidence-based therapies. While controversial, I would posit that reduction in major risk factors would ultimately lead to reduced incidence of CVD, lower need for evidence-based therapies, and move even more of the therapeutic success to risk factor reduction.

The goal of lifestyle modification involves the concept of risk factor reduction. In the world of cardiology we gain respect from our peers by performing successful TAVR procedures, by recannalizing total coronary occlusions, by atrial fibrillation ablations, performing and interpreting images, and other procedural successes. But how many cardiologists are respected for their patient population where 100% of the patients are at lipid goals, or better yet, where the incidence of coronary disease in a 20-year cohort in one practice is half of the national average? For one thing, we don’t have the data to even assess these questions, and worse, there is no compensation for lowering CVD risk by lifestyle guidance, compared to inserting a coronary stent, performing an AF ablation or implanting a pacemaker. While we regard procedural prowess highly, and train our next generation on how to gain that prowess, we learn and teach almost nothing about behavior modification that likely would have the most impact on the long term goal of better health.

Lifestyle (behavior) modification must consider food and nutrition, physical activity, stress, risky habits like smoking, alcohol and recreational drugs, health literacy, and patient participation in their care (patient-centered care). In terms of lifestyle, we are trained to consider diet as it affects lipids, excess alcohol, problems with recreational drugs, and smoking cessation, and of late, even more compelling evidence of the value of exercise (Eckel et al.).² Based on the data, we need to now talk about exercise prescriptions, addressing types and frequency of activity.

Modifying lifestyle involves longer office encounters with a patient than the usual 900-second visit, some knowledge of the various lifestyle factors as well as some sense of the type of behavior a patient exhibits. The behavioral psychologists classify patients into different categories, and the approach to patient education and behavior modification depends on the type of behavior pattern for a given patient and on the physician’s engagement in lifestyle modification. In a study of lifestyle modification to lower CVD risk in an urban, underserved population, we found that BMI was the only factor that provoked a physician to offer lifestyle advice and that was focused on diet for weight reduction. The obvious evidence of need for advice came from the observation of the patient’s size. Blood pressure; hyperlipidemia, diabetes, and risky behavior did not have an effect on physician interest in lifestyle advice.

With the time and complexity of knowledge needed to actively practice behavior modification, the whole endeavor might be better done with a team of providers, not necessarily a physician, who can spend the time needed and who have the collective expertise to analyze individual CVD risk, determine individual patient behavior characteristics, discuss dietary detail, exercise prescription, health literacy, stress modification, and tailor programs for individual patients that incorporate patient participation in a team-based care approach.

In a cardiology practice, we may not encounter patients who are healthy and risk free. Most referred patients have a documented or suspected cardiovascular disorder that requires specific therapy. For those patients referred for management of hyperlipidemia or hypertension, who have no evident CVD, or for patients who have been treated and need a detailed secondary prevention program, the ‘lifestyle team’ should be consulted to provide a full package of therapies and advice on how to minimize future risk for cardiovascular disease.

References

1. Ford ES, Ajani UA, Croft JB, et al. N Engl J Med. 2007;356:2388-98.
2. Eckel RH, Jakicic JM, Ard JD, et al. J Am Coll Cardiol. 2014;63(25 Pt B):2960-84.

Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.

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