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For heart-healthy lifestyle, well-rounded approach provides greatest benefits
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As physicians, we know that lifestyle habits have a direct impact on CV health, but the full magnitude and selection of individual lifestyle modifications have not been well validated. Interestingly, new research has demonstrated that practicing a combination of positive lifestyle habits together can have a cumulative benefit.
To help patients realize this benefit, we need to provide them with insight on the importance of adopting a variety of key lifestyle behaviors, in addition to arming them with scientifically backed strategies that they can apply in a real-world setting.
Science supports multi-pronged approach to CV health
Based on the Multi-Ethnic Study of Atherosclerosis (MESA), a multicenter observational cohort study of 6,229 participants, investigators were able to discern the individual and combined effects of different lifestyle modifications on CV outcomes. The research was published in the American Journal of Epidemiology.
Matthew J. Budoff
Adopting four lifestyle behaviors — avoiding tobacco, consistent physical activity, adhering to a healthy diet and maintaining a healthy weight — protected against CHD as well as coronary calcium progression. This translated to a reduced risk for death from all causes by 80% during an 8-year period. The benefits were cumulative: Adhering to a single lifestyle modification resulted in a 21% reduction in risk, increasing to 39% for two modifications, a 51% relative risk reduction for three and 81% for all four (P<.001). The investigators also found benefit on the incidence (development of new calcified plaques) and progression of coronary artery calcification for those patients who maintain these lifestyle modifications. Thus, the investigators concluded that a combination of regular exercise, healthy diet, smoking avoidance and weight maintenance was associated with lower coronary artery calcium incidence, slower calcium progression and reduced all-cause mortality over 7.6 years in the MESA study.
Another example of the compounding benefits of adopting a multi-pronged approach to CV health comes from a recent study published by Hoevenaar-Blom et al in the European Journal of Preventive Cardiology. This study found that adding sufficient sleep — characterized as at least 7 hours of sleep per night — was associated with an enhancement in the benefits of being physically active, eating a healthy diet, not smoking and drinking alcohol in moderation. Compared with people who practiced fewer than two healthy lifestyle habits, those who adhered to four habits had a 57% lower risk for composite CVD and 67% lower risk for fatal CVD. People who added sufficient sleep to these four habits had an even greater benefit: a 65% lower risk for a composite CVD event and 83% lower risk for fatal CVD. The study investigators believe that if participants adhere to all five healthy lifestyle factors, 36% of composite CVD and 57% of fatal CVD could theoretically be prevented or postponed.
Help patients implement key lifestyle factors
Quitting smoking: Of the four key lifestyle behaviors, research suggests that smoking avoidance may play the largest role in reducing risk for CHD and mortality.
Physical activity: The American Heart Association recommends that Americans perform at least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise (or a combination of moderate and vigorous activity). This translates to 30 minutes per day, five times per week. For some patients, this is a tough goal to achieve. However, it is important to note that patients can also experience benefits even if they divide their time into two or three manageable segments of 10 to 15 minutes per day.
Heart-healthy diet: A Mediterranean diet consisting of daily intake of breads, vegetables, fruits, beans and olive oil and weekly intake of fish is associated with cardioprotective benefit. An emphasis is placed on eating fish as a primary protein, while red meat is recommended only a few times a month and in very small amounts. Consistent with the Mediterranean diet and US nutritional guidelines, all Americans should consume fish at least two to three times a week.
The PREDIMED study recently published in The New England Journal of Medicine was the first major clinical trial to specifically measure the impact of the Mediterranean diet on CV risk. Researchers followed men and women aged 55 to 80 years for an average of 4.8 years. These participants were initially free of CVD, although they had either type 2 diabetes or three major CVD risk factors at baseline, including smoking, hypertension, elevated LDL, low HDL, overweight or obesity, or family history of premature CHD. The results were significant: Major CV events were reduced in more than 7,000 high-risk persons. Participants experienced an absolute risk reduction of approximately three major CV events per 1,000 person-years and a relative risk reduction of approximately 30%.
These are statistics that should resonate with patients. Getting patients to eat more fish can be a challenge as the average American is misinformed about its benefits or is not confident with preparation methods; getting a weekly serving of fish can be as easy as opening a can of tuna, yet many patients still avoid it. It is estimated that Americans average about one serving per week, despite consistent recommendations that adults eat a minimum of two or more servings. Similar recommendations for two or more servings of fish per week are also in place for children and pregnant women.
Maintaining a healthy weight: A recent study on weight and exercise from the University of Washington’s Institute for Health Metrics and Evaluation found that adding exercise to a patient’s regimen, without other healthy lifestyle habits, may not be enough to maintain a healthy weight. According to the findings, Americans are exercising more today than a decade ago, but obesity rates continue to rise. Without also following a healthy diet, research has shown it is difficult for most people to lose weight by just exercising.
Strategies for starting a dialogue
How can we help patients make simple changes to protect their hearts? Here are a few techniques to consider when talking to patients about living a healthy lifestyle:
- Start by opening the dialogue. Opening up conversation about how their diet impacts CV health allows patients to comfortably ask questions and allows the physician to share simple methods to change their diets to improve their health.
- Ask questions early on. Don’t wait until patients are in the exam room to ask questions about their lifestyle. A scientific statement published in Circulation recommends the use of standardized patient surveys to assess patients’ CV health. By asking questions about symptoms and quality of life, physicians could uncover issues and help patients live longer.
- Talk about what matters to patients. Research from the AHA shows that patients are more motivated to make healthy lifestyle changes if the changes improve how they feel, rather than increase life expectancy. Discuss how certain lifestyle changes can give patients more energy throughout the day, help them sleep better and reduce daily stress.
- Follow your own advice. To really inspire patients to make lifesaving changes, we, as physicians, need to embrace healthy lifestyles too and insert ourselves into the conversation with patients about what it means to live a heart-healthy life.
- Share resources. Patient-related information is available on a number of professional websites such as the AHA’s heart.org and resources to help Americans increase their weekly consumption of fish for CV health can be found at the National Fisheries Institute’s getrealaboutseafood.com.
Disclosure: Budoff is currently serving as an educational consultant on CVD to the National Fisheries Institute, a nonprofit organization that offers a health-focused website with fish tips and recipes.