Portal de Periódicos da CAPES

Counseling Patients to Make Cardioprotective Lifestyle Changes: Strategies for Success

2008; Wiley; Volume: 11; Issue: 1 Linguagem: Inglês

10.1111/j.1520-037x.2007.07662.x

1751-7141

Barry A. Franklin, Thomas E. Vanhecke,

Obesity and Health Practices

Atherosclerotic cardiovascular disease (CVD) causes more deaths per year than the next 5 leading causes of death combined,1 and cigarette smoking, hyperlipidemia, hypertension, diabetes, or combinations thereof, are present in 80% to 90% of persons with CVD.2 On the other hand, Framingham Heart Study3 participants who were free of CVD risk factors at age 50 were at very low risk of ever developing the disease. These conventional risk factors and their resulting health risks are largely preventable with a healthy lifestyle.4 As cardiovascular (CV) health care providers, we need to become champions of achieving healthy lifestyle overhauls in our patients to halt the progression of CVD. Our younger patients should be counseled to modify their lifestyles so that they don't gain weight, develop hypertension or hypercholesterolemia, or start smoking. For older patients, aged 40 to 50 years, who already have ≥2 major CV risk factors, the heightened lifetime risks of developing CVD (69% for men and 50% for women) suggest the need to become even more aggressive with preventive therapies.3 Performing a simple search on the Internet will uncover a well-documented fact: we are not very good at changing behavior in our patients. In fact, type in the term myths about changing behavior and the first result that appears is a business magazine article that proclaims "Ninety percent of patients who've had coronary bypasses don't sustain changes in the unhealthy lifestyles that worsen their severe heart disease and greatly threaten their lives."5 Instead of being highlighted as an example of a behavioral change failure, what can we do to improve our rates of getting patients to make the necessary changes to lessen their risk? In this commentary, we provide some useful suggestions and strategies for counseling patients to change and maintain lifestyle behaviors that may favorably impact future CV morbidity and mortality. According to a recent telephone survey of 153,000 adults in the United States, only 3% adhere to 4 healthy lifestyle characteristics, including not smoking, maintaining a normal body weight, eating adequate daily servings of fruits and vegetables, and exercising regularly.6 Almost 10% of the respondents adhered to none of these practices.6 Unfortunately, recent estimates suggest that such poor health behaviors contribute to more than one-third of deaths in the United States, based on data from the Centers for Disease Control and Prevention.7 Should physicians and allied health professionals be doing more to counsel patients regarding the need for lifestyle modification? Prevention is, after all, a core component of medicine, and shirking this responsibility constitutes a direct violation of one of the central tenets of the Hippocratic oath, that is, do no harm. Many physicians and paramedical personnel, however, have little or no training in the specific skill sets required for health promotion, especially application of behavioral theory and practice. It should also be acknowledged that most physician practices are already overstretched in caring for their patients' acute health concerns. Reimbursement for patient counseling and education is suboptimal, to say the least, and requires careful documentation. In addition, the current health care environment exacerbates the problem by providing paltry payments for patient counseling while making it financially attractive to prescribe medications or perform diagnostic studies or therapeutic interventions. Despite the well-established benefits of regular physical activity, a national survey found that only 34% of respondents reported being counseled about exercise during their most recent physician office visit.8 In another relevant report, only 42% of 12,835 obese adults (body mass index [BMI] ≥30 kg/m2) who had seen their physician for a routine examination during the previous 12 months reported that they had been advised to lose weight.9 Others suggest that the counseling rate for obesity management may be even lower.10 A series of sobering studies also indicate that physicians in the United States counsel their patients about the need for smoking cessation far less frequently than called for by national health objectives and contemporary practice guidelines.11-14 Many patients felt that their health care provider could do more to help them to secure the tools necessary to quit smoking, whereas others cited a lack of follow-up regarding their progress in quitting. Collectively, these and other recent reports15 suggest that physicians and/or their support staff often miss opportunities to counsel patients regarding the need for substantive lifestyle modification. Yet, numerous studies have now shown that brief (ie, 3–5 minutes) physician intervention during an office visit can play a critical role in patient implementation and outcomes. Today, many experts in the medical community embrace a common treatment approach in the battle against modern chronic diseases: the extrapolation of contemporary pharmacotherapies as a first-line strategy to stabilize latent or overt CVD. This approach sends the wrong message to the population at large—that there is a "quick fix" for CV health in the form of antiatherosclerotic medications (eg, aspirin, β-blockers, statins) or perhaps as a cardioprotective "polypill," which may come to fruition in the near future.16, 17 Consequently, the salutary effects of concomitant lifestyle modification are often overlooked and underemphasized. Barnard and colleagues18 reported that an intensive diet (<10% calories from fat [<3% saturated fat]) and exercise intervention in patients taking cholesterol-lowering drugs resulted in additional substantial reductions in total cholesterol, low-density lipoprotein cholesterol, and triglycerides (19%, 20%, 29%, respectively). Similarly, Sdringola and associates19 demonstrated that intensive risk factor modification that combines a very low-fat diet (<10% calories as fat), weight control, regular exercise, and lipid-active drugs dosed to target goals (low-density lipoprotein cholesterol 45 mg/dL, triglycerides <100 mg/dL) further reduced CV events, deaths, and revascularization procedures compared with either standard care cholesterol-lowering medications and an American Heart Association diet or a strict low-fat diet (<10% of calories) without lipid-modulating agents. Accordingly, these and other recent studies20-24 have now shown that the effects of lifestyle change and drug therapy on CV risk reduction appear to be independent and additive.17 Recently, Iestra and associates25 conducted a systematic review of the literature regarding the effect of generally accepted lifestyle recommendations and cardioprotective medications on mortality in patients with documented coronary artery disease. Prospective cohort studies and randomized controlled trials of coronary patients were included if they reported all-cause mortality and had at least 6 months of follow-up. Lifestyle changes (ie, smoking cessation, increased physical activity, moderate alcohol use, and combined dietary modifications) were associated with impressive mortality reductions (20% to 45%), the magnitude of which were similar to or greater than that observed with low-dose aspirin, β-blockers, statins, and angiotensin-converting enzyme inhibitors after myocardial infarction (Table).26, 27 Lifestyle modification is highly beneficial in patients with documented CVD and those at increased risk. For such patients, this may entail changing longstanding deleterious behaviors that may be linked to stressful situations, psychosocial variables, work and/or home environments, inadequate education, economic factors, or combinations thereof. In the remaining sections, we provide practical and research-based suggestions/strategies for counseling patients on cardioprotective lifestyle changes and ways to favorably modify their behavior. The likelihood that your patient will or will not engage in a particular behavior is governed in large part by their expectations or predictions of the effects and consequences of that behavior in relation to their goals and objectives. Changing behavior is easier said than done; however, it is not impossible. Our brains have extraordinary plasticity—we can continue learning complex new things throughout all decades of our lives—assuming we remain truly active and engaged.5 So how do we engage our patients in actively making lifestyle changes? Behavioral studies have shown that change is often not a linear, gradual movement across a spectrum. Instead, lifestyle change is progressive, regressive, spiraling, or static. Most people believe that a single behavioral change is easier to make and sustain, when in fact multiple simultaneous changes are often easier because they quickly yield benefits.28 Surveillance studies show that physical activity sharply declines during or following adolescence, at which time other modifiable risk factors set in, such as poor dietary choices or cigarette smoking.29 Interestingly, the techniques used for changing detrimental behavior in certain adolescents may be applicable to our adult patients. Lerner, a leading psychologist and developmental scientist in the field of adolescence, has multiple publications that describe the "5 C's" of getting adolescents to change.30, 31 We can borrow the 5 C's to facilitate CV behavioral risk change in our patients in much the same context as they are used in adolescents. The 5 C's stand for competence: instilling or bringing forth social, vocational, and health competence into the individual; confidence: providing an inner willpower to succeed using compelling, positive visions of the future; character: ensuring that these proposed lifestyle changes are fundamental and important to their well-being (by making sure that these changes will make the individual a better person by strengthening and enhancing their personal, social, and spiritual lives); connection: getting your patients to work collaboratively with their physicians, peers, spouses, and other people in their lives to achieve their lifestyle goals; and caring: providing a sense of compassion for themselves (change is best inspired by emotional appeals that encompass the considerations of those involved). This includes a doctor's rapport with their patient, a spouse giving time, or children becoming a health advocate for their parents. Identifying or predicting and then removing factors that form the barriers to change are integral to achieving successful change. Lack of or a poor social support system or social isolation is a barrier and therefore is a factor associated with poor outcomes in these patients.32, 33 This is overcome by creating or having patients join existing support groups such as weight loss programs, physical activity clubs, or fitness groups. Financial difficulties are often a chief factor reported by many patients as reasons for not being successful. Eating a "heart healthy" diet is more expensive than eating caloric-dense convenient food. To overcome this, patients must be systematic in acquiring food and schedule routine leisure-time physical activity. Patients who are unable to afford structured physical activity that entails membership fees should be encouraged to exercise outdoors in their neighborhood or walk indoors in public facilities such as shopping malls. Practitioners should anticipate patients declaring that they are too busy or do not have the time to engage in physical activity or make healthy lifestyle changes. Finally, failure to address underlying psychosocial factors such as depression, anger, denial, apathy, chronic life stress, personality factors, and character traits—factors commonly clustered in patients with CVD—can be obstacles to a healthy lifestyle as well as directly promote coronary artery disease.32, 33 The Stages of Change Model can help identify patients who are positively interested in or, on the other hand, absolutely unwilling to change their health behavior.34 Tailoring messages on lifestyle counseling to patients' individual motivational characteristics increases program effectiveness. This model includes 6 stages of intentional (or unintentional) behavior change that may occur over time: precontemplation: patients express lack of interest in making lifestyle changes; contemplation: patients are "thinking" about making a desired change; determination: patient has taken some behavioral steps and intends to take action in the next 30 days; action: patients have been meeting the above-referenced (determination) criteria on a consistent basis for <6 months; maintenance: patients have been in action for ≥6 months; and relapse: patients fall or slip back into former (unhealthy) lifestyle habits (Figure).34 Progressive stages of readiness for behavior change. Deviations from serial progression (ie, either temporary or permanent exits) are most likely to occur during the determination and maintenance phases, respectively. Adapted from Prochaska and DiClemente.34 Patients can be evaluated for the stage of readiness they express before being counseled to change a behavior. Thus, while a precontemplator may need perception alteration, the contemplator may require a critical analysis of the pros and cons of changing behavior. Similarly, exploring alternative action plans, providing specific instructions (step-by-step guides), offering positive personal feedback, and halting recidivism may be employed for the determination, action, maintenance, and relapse stages, respectively. Motivational interviewing is a therapeutic approach used by the health care provider during patient encounters to help encourage a behavioral transformation. This technique has been shown to be effective in helping some postmyocardial infarction patients quit smoking35 and has been recommended as an approach to facilitate dietary change in patients with poor eating habits.36 In short, motivational interviewing is a type of talk therapy used to change longstanding behavior. To accomplish this, a practitioner must convey understanding, acceptance, and interest in the patient as an individual.35 The first step is to open the door to change by using empathy to identify what maintains behaviors. An example would be expressing to a smoker that you understand how difficult it is to stop smoking and identifying triggers that supply the urge to smoke in the individual. Getting patients to consciously recognize what maintains a particular behavior is crucial.35 Oftentimes these patients are not consciously aware of these behaviors; therefore, it is important to help patients change their perception. The next step is getting the individual to understand and accept the change. Counterproductive arguments must be avoided at this time and interviewers should strive to encourage the patient to hear themselves express why they want to (or should) change.36, 37 This is most effective using specific questions directed at the patient about why they need to change this behavior. More important, the patient needs to be allowed to speak—this is vital. The next step is to help the patient become independent and self-motivating. Handling resistance and dealing with expected letdowns are crucial to success. An example would be to remind the relapsed smoker not to "quit quitting" and help get them back on track. Setting appropriate goals is the final step. At this point, setting goals in stages can be less daunting and more effective for the patient. For example, a modest weight loss over a 2-month period is easier to focus on than the full weight loss needed to get the patient to their ideal body weight. Motivational interviewing, if correctly utilized, can be a powerful tool for helping patients change.35 Also, don't hesitate to seek help in achieving your objectives; cardiac rehabilitation programs, weight-loss specialists, nutritionists, psychologists, and other health care providers working in unison can provide invaluable assistance in this regard. Contemporary guidelines and recommendations for CV risk reduction are widely available, as are clinically relevant threshold values for hypertension, cholesterol and its subfractions, overweight/obesity, physical activity, cardiorespiratory fitness, and impaired fasting glucose. For many patients, however, setting initial goals for selected risk factors (eg, body weight reduction, increasing physical activity) may be unrealistic and discouraging, especially if such standards are literally embraced. Using conventional norms, the patient who is 172.9 cm and weighs 137.3 kg (BMI, 45.5 kg/m2) might be inappropriately advised to reduce his body weight to a "normal" range (ie, to 75.6 kg), since this represents a BMI corresponding to 25 kg/m2. Our approach would be to ask this patient about an initial goal weight he felt he could achieve. Regardless of his response, if it moved him in the right direction (ie, 40% between 1980 and 2000. Recently, researchers developed a statistical model, which attributed 91% of the observed decrease in deaths to reductions in major risk factors (44%) and the widespread implementation of evidence-based medical therapies (47%).38 In contrast, revascularization by means of coronary artery bypass grafting or coronary angioplasty and stents for stable or unstable disease accounted for only 7% of the overall mortality reduction. The authors concluded that future strategies should actively promote population-based prevention by reducing risk factors. The treatment of CVD has evolved from simple lifestyle modification in the 1960s, largely focused on a "prudent diet" and regular exercise, to an array of costly medical and surgical interventions that too often fail to address the underlying causes—high-fat and high-cholesterol diets, cigarette smoking, hypertension, overweight/obesity, diabetes, and physical inactivity. Intensive measures to control risk factors with diet, drugs, exercise, and smoking cessation, especially in combination, have now been shown to stabilize or even reverse the otherwise inexorable progression of atherosclerotic coronary artery disease. Added benefits include a reduction in anginal symptoms, decreases in exercise-induced signs or symptoms of myocardial ischemia, fewer recurrent cardiac events, an improved quality of life, and diminished need for coronary revascularization. The issue is not information but methods, motivation, and behavioral changes. Accordingly, patients should be directed toward comprehensive programs designed to change behavior and facilitate CV risk reduction, using individually tailored interventions to circumvent or attenuate barriers to participation and adherence. The challenge is yours!