Approximately 36% of all deaths that occurred in the United States in 2000, most of which were a result of heart disease, were attributable to behavioral or lifestyle factors, including tobacco use, poor diet, physical inactivity, and alcohol.1 In 2009, it was estimated that high blood pressure accounted for 45% of all cardiovascular deaths, followed by overweight-obesity, physical inactivity, high low-density lipoprotein (LDL) cholesterol, smoking, high dietary salt, high dietary trans-fatty acids, and low dietary omega-3 fatty acids.2 In persons under the age of 70, smoking was the single largest risk factor for cardiovascular death.

Although genetic factors undoubtedly contribute to individual susceptibility to these risk factors, a prime ingredient of this risk is the person’s behavior. The costs of treating heart disease are escalating at an increasingly rapid pace due to the widespread use of sophisticated and increasingly expensive treatments such as drug-eluting coronary artery stents, implantable cardioverter-defibrillators, and gene therapy. Most efforts to contain the increase in health care costs have focused on limiting supply (a largely unfulfilled promise of managed care) and imposing some sort of rationing. However, as long ago as 1993, Fries et al3 pointed out that restricting demand could achieve the same objective. They identified six factors, four of which are directly relevant to this chapter. They include the following facts:

1. 
   

   Much disease is preventable.

   
   
2. 
   

   Risky behavior costs money. Lifetime medical costs, which averaged $225,000 per person, have been clearly related to health behavior. For example, costs are approximately one-third higher in smokers compared with nonsmokers.

   
   
3. 
   

   Self-management can result in savings. Several studies have shown that providing medical consumers with information and guidelines about self-management can lower the use of medical services by 10% or more.

   
   
4. 
   

   The promotion of healthy behavior at work successfully reduces costs. This has also been documented in numerous studies.

The resulting tasks for the field of behavioral cardiology in the care of patients with heart disease are as follows: (1) to better identify patients at risk by developing tools that reliably assess behavior that harms and behavior that protects; (2) to educate physicians in the risks associated with lifestyle factors and in managing these risks together with their patients; (3) to develop and test the efficacy and cost-effectiveness of interventions to promote lasting behavior change in patients; and (4) to identify barriers for the implementation of health behavior guidelines in cardiology practice and find ways to overcome these barriers.

This chapter focuses on the major lifestyle or behavioral factors that influence the incidence of coronary heart disease (CHD), as well as the progression of existing CHD, and how they can be modified. These factors are smoking, diet, exercise, and adherence to prescribed medication regimens. They all have an impact on a patient’s prognosis, and they are linked to long-established biologic risk markers, such as blood pressure, cholesterol, triglycerides, and glucose-insulin homeostasis, and more recently identified risk markers, such as endothelial function, oxidative stress, inflammation (eg, C-reactive protein), thrombosis/coagulation, and arrhythmia (Fig. 114–1).4 Cardiologists need to be aware of the extent to which lifestyle factors influence a patient’s prognosis, as well as the potential to modify these risks.

In this chapter, we review existing recommendations for health behaviors in the primary and secondary prevention of heart disease5 and review to what extent patients and physicians do or do not adhere to these recommendations. Barriers to behavior change are discussed, focusing on patients, physicians, and the health care system. Some general principles of behavior change are then presented, and examples of behavioral interventions are provided for each health or risk behavior. Although the efficacy of behavioral interventions is typically studied in the context of one single behavior, behavioral risk factors often co-occur, and multiple risk behavior change poses a specific challenge for patients and providers. However, new technologies that monitor and provide instant feedback on risk factors are promising additions to the behavioral management in high-risk CHD patients.

What Are the Recommendations for Primary and Secondary Prevention of CHD that Involve Patient Behavior?

Current guidelines and recommendations by expert panels and major health organizations include a number of more or less specific recommendations for lifestyle interventions for the primary and secondary prevention of CHD. Core targets of these recommendations are the maintenance of optimal body weight; management of cholesterol, blood pressure, and blood glucose; encouragement of physical activity; and avoidance of tobacco.6 Table 114–1 provides an overview of some of the most recent recommendations.6-8

What Is the Reality?

Big gaps exist between treatment recommendations and the care prescribed in clinical practice, as well as between what is prescribed and what is actually achieved. For example, despite the availability of numerous powerful medications, blood pressure is adequately controlled in less than one-third of patients.9 No matter how efficacious an interventional strategy, it is doomed to failure unless it is implemented at the right time and the right dose and followed through by the patient. Adherence is defined as the extent to which (1) providers follow established clinical guidelines in their treatment and (2) patients follow the treatment regimens that they agreed upon with their care providers, including the previously described changes in lifestyle, as well as all prescribed medication. (Historically, the term compliance has often been used interchangeably with adherence. Researchers now prefer the term adherence because it underscores the active role of both patients and caregivers as collaborators in long-term patient care.) Thus, adherence is the key factor in achieving risk factor control and reducing adverse cardiovascular outcomes.

Patients’ Adherence to Lifestyle Recommendations

Despite this obvious notion, nonadherence is one of the biggest problems in clinical practice; rates of failure to fully adhere to a prescribed medication regimen range from 25% to 85%, and <50% of all patients adhere to recommended dietary changes, exercise, and smoking cessation. Recently, data from the Health Professionals Follow-up Study showed that among initially healthy men, 62% of incident coronary artery disease (CAD) events could have been prevented had all men adhered to five low-risk behaviors: not smoking, exercising regularly, eating prudently, consuming alcohol in moderation, and maintaining a healthy weight.10 Importantly, men who initially reported all five risk behaviors but who adopted positive lifestyle changes in at least two areas over time also substantially decreased their risk of incident CAD events (by 27%).

Adherence to recommended pharmacologic interventions is equally important in patients with manifest CAD. Rates of discontinuation of prescribed medication after hospitalization are as high as 46% in the first year after hospitalization.11 Meta-analyses have shown that even partial medication nonadherence (as assessed on a daily basis) significantly increases the risk for mortality after hospitalization for a CAD event.12 The Beta Blocker Heart Trial, for example, showed that β-blocker adherence ⩽75% was associated with a 2.6 times greater risk for mortality within 1 year.13 Interestingly, the recent Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity (CHARM)14 trial showed that poor adherence to medication increased the risk for mortality in CHF patients regardless of whether the patients were taking the study medication or a placebo. This suggests that patients who poorly adhere to their medication might be neglectful of other effective treatments and recommended behaviors; thus, nonadherence to one type of treatment might be a good indicator for general nonadherence.

Nonadherence crosses age and sex groups and socioeconomic strata. However, some risk factors for patient nonadherence emerge consistently from empirical studies. Increasing age appears to be a risk factor primarily for nonadherence to pharmacologic treatments. Paradoxically, patients at highest risk (those with diabetes and heart failure) are also often the least adherent.15 Several characteristics of the pharmacologic and nonpharmacologic regimens also influence patients’ adherence, including long duration of a prescribed intervention, complexity of the regimen, lack of immediate or perceived benefits, and high monetary and/or social costs.16 Next to these are impediments that are inherent to the regimen and thus are modifiable only to a limited extent. Patients’ mental health also plays a critical role. One of the strongest risk factors for poor medication adherence is depression; patients with depression are up to three times more likely not to adhere to treatment recommendations than patients without any depression symptoms (Fig. 114–2).17,18 There is no systematic evidence to date that shows that treating depression results in improved adherence to cardioprotective medication, but the large impact that this mental health problem has on nonadherence suggests that this link should be investigated more thoroughly.

Physicians’ Adherence to Guidelines

Analyses of hospital records and patient surveys have shown that in the United States as well as in Europe, medication management of CHD patients has steadily improved over the past 2 decades (Fig. 114–3).15,19 Still, there is potential for improvement in guideline adherence, especially in the transition from clinical care to primary practice.

Long-term adherence to recommended medication in the secondary prevention of CAD has steadily improved since the initiation of large quality improvement efforts, such as the American Heart Association’s (AHA) Get With the Guidelines program, but is still far from optimal. For example, an analysis from the Duke Database for Cardiovascular Disease showed that in 2002, almost 20% of patients were not taking aspirin.15 Overall, of all patients who were followed from 1995 to 2002, 30% were inconsistent users of aspirin across the 7 years. Compared with inconsistent users or nonusers, patients who were consistently taking their medication had lower adjusted mortality rates. This was also the case for consistent users of β-blockers and lipid-lowering agents.

Improvements in preventive drug prescribing practices do not necessarily translate to improved risk profiles and clinical outcomes. The recent European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) III study, which includes data from CHD patients from eight European countries, has shown that despite substantial increases in antihypertensive and lipid-lowering drug use from 1995/1996 to 2006/2007, blood pressure control did not improve, the prevalence of obesity increased, and almost half of the patients remained above the recommended lipid levels.19 These data highlight the need for more effective preventive efforts in the long-term management of CHD patients. Treatment decisions in primary care are most often based on the “classic” CHD risk markers of blood pressure, cholesterol, and glucose levels and rely largely on drug therapy. Lifestyle habits are far less frequently discussed,4 even though they contribute to a great extent to the biologic risk profile (see Fig. 114–1). For example, in a US nationally representative study of outpatient visits among patients with diabetes, a major cardiac risk factor, nutrition referrals or on-site nutrition counseling occurred in only 37% of patient visits, and counseling for exercise occurred in only 19% of all visits.20 In contrast, the National Health and Nutrition Examination Survey (NHANES) showed that of 3497 patients with hypertension, 84% reported that they had received some form of lifestyle modification counseling.21 Percentages of patients who reported having received counseling were lower in younger patients, women, and those with fewer cardiovascular risk factors, although the guidelines make no distinction according to these characteristics.22

Barriers to Adherence in the Health Care System

Patients often lack the knowledge and motivation to make behavioral changes, and the training of cardiologists rarely includes substantial information on behavior or behavioral intervention. Physicians generally have a low expectation of the effectiveness of behavioral interventions and no particular incentive to implement them, let alone the time to do so. In addition, because no one has pressured the health care system to recognize the importance of making these changes, behavioral interventions are rarely reimbursed. Although primary and secondary prevention guidelines recommend screening for lifestyle risks and give specific advice on the content of patient counseling (eg, how many minutes of activity per day, how many vegetables), according to the most recent recommendations for performance measures for the primary prevention of cardiovascular disease,23 there is “no agreement on what constitutes adequate documentation of diet, physical activity, and alcohol use.” In light of this situation, the recommendation is that “practitioners should strive to capture the healthy and unhealthy aspects of the patient’s habits to provide counseling and observe change over time.”23 Recent (2002) changes in Medicare policy have for the first time introduced the possibility of reimbursing providers such as health psychologists for assessing and treating health behaviors related to medical diagnoses. However, primary and secondary prevention of CHD can only be implemented effectively if all health plans include reimbursement for behavioral counseling, intervention, and education.

Behavioral and lifestyle factors need to be addressed within a context of collaborative management. Heart disease is almost always chronic, and its successful management requires an active collaboration between the patient and health care providers. Health care providers can and should use behavioral techniques to improve patients’ self-care (Table 114–2).

Physicians are usually concerned with poor patient adherence and unhealthy lifestyle, whereas patients are more concerned about their symptoms and emotional distress. Only some physicians ask patients to identify the biggest problems they face in managing their illness and address those barriers.

Given the lack of training in behavioral techniques and the severe limitations on cardiologists’ time, a team approach should ideally be employed. Behavioral interventions tend to require relatively large amounts of time, but nurses, psychologists, dietitians, and social workers can contribute to ensure that this need is met.

Gateways to Behavior Change

Making and sustaining lifestyle changes to promote healthy behavior is a huge undertaking, particularly given the fact that for most people, the environment in which they live largely works against those efforts. The layout of communities in which most Americans live and work seems to discourage physical activity; fast food and other processed food laden with saturated fats and sodium is cheap, quickly obtainable, and convenient; and longer commutes and workweeks conspire against healthy cooking and leisure-time activities. Thus, it should not surprise us that our patients struggle to develop and maintain positive behaviors, even when they know that these behaviors are vital to their health. It is clear that knowledge alone is not sufficient to change behavior; motivation, self-management skills, and structured follow-ups are also needed. We describe here two ways of approaching behavior change, derived from decades of behavioral science research, that may help clinicians and patients think about health behavior.

Interventions Focusing on the Patient

Stages of Behavior Change

Over the past 2 decades, research on the stages of changemodel has yielded valuable insights regarding how, why, and when patients will change their behavior. The stages of change model suggests that behavioral change is achieved in transit through a series of stages, defined as precontemplation, contemplation, preparation, action, and maintenance (Table 114–3).24 The key points in applying this model to counseling for health behavior change are as follows: (1) There is evidence that patients stuck at different stages are likely to have different barriers to making changes; and (2) patient counseling will be more efficient if we tailor it to the specific barriers seen at each stage rather than giving the same messages and offering the same next steps to everyone. For example, offering an exercise prescription is not likely to be useful to a patient who is not even thinking seriously about exercising, just as simply extolling the benefits of exercise in a general way is unlikely to be truly helpful to a patient ready to begin an exercise program.

Motivational Enhancement

A second model that is gaining increasing evidence in its usefulness in patient counseling is motivational interviewing, which has been derived from a longer-form psychotherapy approach to treating addictions25 and successfully adapted to brief counseling for health behavior change.26 In explaining the approach, Rollnick et al27 have described the differences between doctor-patient conversations about health behavior that go well versus those that go badly: “When the discussion goes well, the patient is actively engaged in talking about the why and the how of change and seems to accept responsibility for change.” When the conversation goes badly, the patient is passive/quiet, may superficially agree, or may overtly resist. The heart of the motivational approach is to create the conditions that improve the probability of the interaction going well. The essentials of the approach include the following: (1) acknowledging the understandable mixed feelings patients may have about making a lifestyle change and engaging patients in a discussion of their own sense of the pros and cons of both staying the same and making the recommended changes; (2) asking patients to rate (eg, on a 0-10 scale) how important it is to them to make the recommended change and exploring with them the reasons that make it seem as important as it is, thus eliciting their own personal motivations for making the changes; (3) asking patients to rate their sense of confidence in their ability to make the change, exploring the reasons that make them feel at all confident about the possibility of change and thoughts about what might help them feel more confident; and (4) developing a negotiated plan for next steps and follow-up. Although the content of the discussions is important, what characterizes the spirit of motivational interviewing is thought to be even more so. That is, the use of an empathic, nonconfrontational style is essential to engage the patient in an exploration of the possibilities of change, rather than a defense of the status quo. The approach honors patient autonomy and seeks to guide patients toward change rather than directing them. There is good evidence that the greater amount of time that the patient spends discussing the possibility and process of changing, the greater the chances are of the patient actually making the change, and the approach lends itself very well to follow-up discussions over a period of ongoing visits.

Interventions Focusing on the Physician and the Health Care System

A number of studies have focused on improving the consistency and skillfulness with which physicians address health behavior issues with their patients. The most successful methods typically include conducting health risk assessments for patients, which typically have the effect of activating the patients regarding these issues, as well as emphasizing the needed health behavior change for the physician at the time of a visit. This approach has its simplest expression in treating smoking as a vital sign, with information elicited by a medical assistant in office practice settings and more extensive screenings and interventions taking place in inpatient and cardiac rehabilitation settings. Approaches such as chart stickers alerting to behavioral risk factors have been widely tested in paper medical records, and electronic health records offer the promise of potential assistance in flagging and organizing data on health behavior, although at least at this point, much of the potential has remained unrealized as recent surveys suggest that most providers use only the rudiments of the available systems at this time.28

Smoking Cessation

Smoking kills >400,000 Americans every year, and more than half of these deaths are due to cardiovascular disease (CVD) and stroke. For many years, smoking has been recognized as one of the “big three” risk factors for CVD (the others being hypertension and hyperlipidemia), and it is responsible for approximately 30% of cardiovascular morbidity and mortality. Smoking more than doubles the incidence of CAD, and it increases mortality by 70%. In interaction with other risk factors, smoking contributes to CVD through a number of biologic pathways involving the central and peripheral nervous systems, the walls of blood vessels, the coagulation system, and the immune system.