For many cardiologists, advising patients on healthy lifestyle behaviors is a key component of daily practice. While a substantial portion of one’s risk for cardiovascular disease can be attributed to genetic susceptibility, lifestyle factors also have a significant role in managing cardiovascular risk and disease.1,2
In a prospective cohort study published in June 2023 in the European Journal of Preventive Cardiology, Jia et al aimed to elucidate the contributing roles of lifestyle and genetic factors in the risk of developing valvular heart disease (VHD) among 499,341 individuals without VHD at baseline. Smoking, diet, alcohol intake, physical activity, and sleep comprised the lifestyle factors examined in the study.3
Compared with participants with an unhealthy lifestyle, the results showed a lower risk of VHD in those with intermediate (hazard ratio [HR], 0.81; 95% CI, 0.76–0.86) and healthy lifestyles (HR, 0.81; 95% CI, 0.76–0.87) over a median follow-up period of 10.8 years. Additionally, this association was found to be independent of genetic risk.3
These findings highlight the potential role of lifestyle interventions in reducing the global burden of VHD, the authors concluded.3
To discuss effective methods of counseling patients on lifestyle changes to minimize the risk of VHD, we interviewed the following experts:
- Neel Chokshi, MD, MBA, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania, medical director of the Penn Sports Cardiology and Fitness Program, and director of the Penn Center for Digital Cardiology in Philadelphia, Pennsylvania
- Katarzyna Gil, MD, clinical assistant professor of internal medicine and multi-modality imaging cardiologist at The Ohio State University Wexner Medical Center in Columbus, Ohio
- Justin Bachmann, MD, MPH, cardiologist and assistant professor of medicine, biomedical informatics, and health policy at Vanderbilt University Medical Center in Nashville, Tennessee
- Mariell Jessup, MD, FAHA, chief science and medical officer of the American Heart Association (AHA)
Recent research by Jia et al found that adherence to a healthy lifestyle is linked to a reduced risk of VHD, regardless of genetic susceptibility.3 What has been your experience with counseling patients to begin lifestyle modifications in an achievable and sustainable way to reduce heart disease risk? What are some counseling methods that you’ve been successful with?
Dr Chokshi: A key aspect to addressing lifestyle changes is getting an accurate sense of a patient’s daily routine and the social determinants of health that may be contributing to their cardiovascular risk. It is also important to include the patient in identifying areas for improvement and in the design of the intervention. The effectiveness of lifestyle interventions hinges upon these factors.
Dr Gil: I find it helpful to take time to understand each patient’s motivation and lifestyle before counseling. This allows me to come up with a personalized plan that is realistic and tailored to their needs, preferences, and circumstances. Breaking down larger goals into smaller achievable targets and encouraging patients to focus on gradual progress, rather than immediate and drastic changes, increases the likelihood of them adhering to the plan.
Assistance and support are more effective than lectures. It is also crucial to recognize which patients might require additional support from the interdisciplinary team. Positive reinforcement cannot be overestimated, so I remember to celebrate every little step forward during appointments.
Dr Bachmann: Counseling techniques are highly individualized to both clinicians and patients. In my own experience, I’ve found motivational interviewing to be very effective.4 This is a collaborative, goal-oriented communication technique that focuses on eliciting the patient’s own reasons for wanting to begin lifestyle change. Interested clinicians can learn more about motivational interviewing from various organizations including the Motivational Interviewing Network of Trainers.
Dr Jessup: The causes of valve problems can often be linked to birth defects, related to age, or caused by another condition. Although you cannot reverse damage to a heart valve, in some cases you can slow further damage by managing other heart conditions and risks. Managing cardiovascular diseases and risks by eating healthy, exercising regularly, and not smoking can help keep valve disease symptoms at bay. Of course, more developed heart valve disease may require intervention beyond exercise, such as medication or a surgical procedure. In general, lifestyle modifications help people manage the consequences of heart valve disease more effectively—lifestyle modifications are for everyone.
Patients in food and health care deserts face various challenges with beginning and maintaining healthy lifestyle modifications. Can you discuss some of those issues and the unique challenges physicians face in counseling this population on lifestyle modifications to reduce the risk for VHD?
Dr Chokshi: The guidance on lifestyle modifications for valvular disease is the same as for cardiovascular disease prevention in general. Financial aspects often pose an obstacle to improving lifestyle, specifically diet. Processed foods can be more cost-effective, and individuals are often trying to provide for their families within a limited budget. Similarly, working patients often rely on fast food options for convenience in addition to cost benefits.
Additionally, physicians spend significant effort educating patients on foods and dietary habits that may be unhealthy for their heart. Performing this effectively takes time and effort from both the patient and clinician to customize strategies for each situation. Relatedly, coaching on exercise, smoking cessation, and sleep all require significant time and expertise to be effective. At our institution, we have specific consultations with a dietician, exercise physiologist, and smoking cessation experts to address these challenges. However, there is limited reimbursement for these visits, making such services challenging to access for patients.
Dr Bachmann: Social determinants of health have a marked impact on our patients, particularly those living in food or health care deserts. It’s important for clinicians to have a way of connecting these patients with resources that can help them navigate a challenging environment with regards to their health. The best way to start is to have a discussion with our colleagues in social work about the availability of such resources—the work they do is incredibly important.
Dr Jessup: Making lifestyle changes can be difficult, even when we know we should. In a scientific statement, the AHA outlined 5 issues that make it harder to adhere to healthy eating patterns: targeted food marketing, structural racism, neighborhood segregation, unhealthy built environments, and food insecurity—also known as nutrition insecurity.5 Creating living environments that facilitate a heart-healthy diet and enable physical activity is a public health imperative.
An important facet of our work at the AHA is to make healthy living possible for everyone. A healthy lifestyle has been associated with much more than a reduction in heart disease—or heart valve disease in this case; it can also reduce the incidence of diabetes and hypertension, for example.
What barriers have patients expressed to you that impede their efforts to adopt healthier lifestyle behaviors such as smoking cessation, decreasing alcohol consumption, eating a more nutritious diet, increasing activity, and improving sleep hygiene, and what are some ways that you address these barriers in practice?
Dr Chokshi: Stress in all forms—financial, work-related, familial, personal—is a frequent barrier to behavior change. A key strategy is providing multiple options for patients to impact their heart health and then utilizing a shared decision-making process to identify 1 specific intervention to start. Targeting multiple problems, as they often cluster, can be a setup for failure.
It is important to engage the patient in designing the intervention and goal setting to ensure the change is feasible. For example, a patient may not have time to formally exercise due to a busy work schedule. One feasible strategy for them may be to walk 30 minutes during their lunch break, perhaps to go pick up their lunch. Doing so on a daily basis would provide a meaningful dose of physical activity.
It is also important to design strategies that could be sustained by patients over time, as any meaningful impact on valve or coronary health requires long-term change. Additionally, technology such as wearables, app-based exercise and nutrition programs, and gaming have increased our ability to get creative in developing programs to overcome obstacles for patients.6
Dr Gil: Lack of motivation, knowledge, social support, time, as well as financial constraints and emotional factors can all decrease the chance of a patient making long-term lifestyle changes. Individual patients may have unique barriers, and I tailor my approach accordingly. I address each issue individually and focus on setting one manageable and realistic goal at a time.
Providing education, resources, and evidence-based information increases awareness and understanding. Dedicating time to understanding patients allows me to offer strategies for overcoming setbacks or obstacles. I do not forget to ask patients for their feedback regarding solutions that I offer.
Dr Bachmann: A major barrier for many patients is their home environment, which may not be conducive to goals such as stopping smoking or drinking alcohol, for example. My clinical focus is cardiac rehabilitation, and 1 of the reasons it is so effective is that it provides a place for patients to participate in physical activity in a social environment that promotes healthy lifestyle behaviors.
Dr Jessup: Symptoms of heart valve disease, such as fatigue, lightheadedness, and shortness of breath, can inhibit physical activity and may be dismissed as normal signs of aging. In addition, efforts to stop lifelong habits, such as smoking or alcohol use, can put stress on the mind and body, making these changes particularly difficult when a patient is already experiencing cardiovascular health issues.
Change is hard, and too often, people can only see a huge change in their habits as meaningful. The AHA encourages small steps at first, with tiny goals, as these ultimately add up to significant benefits and success.
From Wii Sport to virtual reality, there are now numerous ways for patients to be more active. What are some benefits and disadvantages of technology-based activity for patients at risk of VHD?
Dr Chokshi: Any degree of physical activity counts towards improving cardiovascular health, with more activity having incremental benefit. The key is for patients to engage in activity that will be sustainable in the long run. Technology-based programs often provide engagement and enjoyment that are useful to this end. Competition and gamification strategies have been shown to promote physical activity.7 Similarly, engaging individuals with their social networks, such as family and friends, can help increase participation in walking.
Tech interventions like video games can leverage both of these behavioral strategies to promote cardiovascular health. Pragmatically, this may also provide a means for families to exercise together. I frequently play “Just Dance” on the Wii with my 10-year-old and 7-year-old. Of course, there are likely some health benefits from outdoor or “live” activities such as weight bearing or resistance training and exposure to sunlight. Therefore, virtual activities should probably be utilized as part of a broader exercise program.
Dr Bachmann: Technology-based activities have a lot of promise, and I think it is great for patients to use these tools. One of the chief advantages of virtual and augmented reality tools is that they promote access, as patients can participate in these activities at home. The major disadvantages are the cost and learning curve involved in using these technologies. At present, virtual reality has a relatively steep learning curve, as many of the current headsets have a complicated setup process, such as requiring measuring interpupillary distance, for example.
Dr Jessup: Only about one-half of Americans meet the recommended guidelines for physical activity.8 A big reason for that is that many adults and children choose sedentary “screen time” over being physically active. Meeting people where they are with incremental change is important for people who are not engaging in any activity—and virtual game play can be a great way to do that. Any physical activity is better than none, and while participating in actual sports is ideal, active gaming compares well with sitting in a chair.
- Kessler T, Schunkert H. Coronary artery disease genetics enlightened by genome-wide association studies. JACC Basic Transl Sci. 2021;6(7):610-623. doi:10.1016/j.jacbts.2021.04.001
- Zeng L, Talukdar HA, Koplev S, et al. Contribution of gene regulatory networks to heritability of coronary artery disease. J Am Coll Cardiol. 2019;73(23):2946-2957. doi:10.1016/j.jacc.2019.03.520
- Jia C, Zeng Y, Huang X, et al. Lifestyle patterns, genetic susceptibility, and risk of valvular heart disease: a prospective cohort study based on the UK Biobank. Eur J Prev Cardiol. Published online June 1, 2023. doi:10.1093/eurjpc/zwad177
- Mifsud JL, Galea J. Motivational interviewing and outcomes in primary preventive cardiology. Br J Cardiol. Published online November 30, 2021. doi:10.5837/bjc.2021.047
- Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association. Circulation. Published online November 2, 2021. doi:10.1161/CIR.0000000000001031
- Santo K, Redfern J. Digital health innovations to improve cardiovascular disease care. Curr Atheroscler Rep. Published online October 3, 2020. doi:10.1007/s11883-020-00889-x
- Mazeas A, Duclos M, Pereira B, Chalabaev A. Evaluating the effectiveness of gamification on physical activity: systematic review and meta-analysis of randomized controlled trials. J Med Internet Res. Published online April 1, 2022;24(1):e26779. doi:10.2196/26779
- Tsao CW, Aday AW, Almarzooq ZI, et al; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation. Published online January 26, 2022. doi:10.1161/CIR.0000000000001052