Free Pass? Lifestyle Slips for Patients Starting Certain Preventive Meds

Patients started on lipid-lowering or antihypertensive medication are more likely to gain weight and be less physically active than those who aren’t started on these preventive drugs, according to a large analysis of the Finnish Public Sector study.

The finding raises concern about the so-called “substitution” hypothesis whereby patients may view the perceived effectiveness of medication as giving them a free pass when it comes to important lifestyle changes needed for the prevention of cardiovascular disease, say researchers.

“I think attention should be paid to lifestyle change during the process of initiating medication,” lead investigator Maarit Korhonen, PhD (University of Turku, Finland), told TCTMD. “I understand it’s hard for patients, as well as physicians,” but the most recent prevention guidelines also recommend supplemental strategies, including cognitive behavioral approaches, such as motivational interviewing, and a multidisciplinary and team-based strategy to help modify a patient’s lifestyle. These approaches can be individualized in order to keep patients on track with the needed changes, she said.

There is mixed evidence when it comes to lifestyle change following the initiation of preventive medical therapy, said Korhonen.

Some studies have suggested physical activity is less among statin users and those taking blood pressure-lowering medication, while data from the National Health and Nutrition Examination Survey in the early 2000s showed these patients ate fewer calories and consumed less saturated fat than nonusers. Those trends were reversed in later surveys, however. Also, previous cross-sectional studies tended to be small, said Korhonen, adding there is a lack of longitudinal data testing the substitution hypothesis, as well as a lack of data in primary prevention patients.

Effective prevention is comprehensive and not piecemeal. Parag Joshi

The new study, published online February 5, 2020, in the Journal of the American Heart Association, included Finnish adults free from cardiovascular disease at baseline who completed two or more consecutive surveys over 4-year intervals between 2000 and 2013. All medication use was ascertained through pharmacy-claims data. In total, there were 8,837 patients who started lipid-lowering or antihypertensive therapy, 26,914 prevalent users, and 46,021 participants who didn’t start therapy.

From baseline, there were significant increases in body mass index among initiators, prevalent users, and nonusers, but the adjusted body mass index was 0.19 kg/m2 higher among those who started medical therapy compared with those who were not taking lipid-lowering or antihypertensive therapy. Similarly, physical activity assessed as metabolic equivalent of task hours per day was 0.09 lower in medication users than in nonusers.

Alcohol consumption and smoking prevalence among those who started medical therapy decreased to a larger extent when compared with those not on lipid-lowering or antihypertensive agents. Overall, those on medical therapy drank less per week (-1.85 g/week; 95% CI -3.67 to -0.14) and smoked fewer cigarettes per day (-0.34; 95% CI -0.60 to -0.08) than those not taking lipid-lowering or antihypertensive therapy.         

“Even though they reduced their smoking and alcohol consumption, 70% of smokers who initiated medication continued to smoke after starting and almost 60% of those who were heavy drinkers before medication initiation continued to drink heavily,” said Korhonen, tempering the positive development. “The recommendations are pretty clear that medication initiation should be accompanied with lifestyle change, which should actually be started before starting medication and continued while on treatment.”

Getting Away With Little ‘Cheats’

Karol Watson, MD, PhD (David Geffen School of Medicine at the University of California, Los Angeles), who wasn’t involved in the study, said the substitution hypothesis can play out in real-world clinical practice.

“Just today, a patient who I started on blood pressure and cholesterol medication a few months ago admitted that he was ‘cheating’ on his diet more now,” she told TCTMD. “He knew it was bad for him and we had discussed diet and exercise extensively, but he thought he could ‘get away with it now.’” She added that patients know the right thing to do but “feel like they’re ‘protected’ from the little cheats now that they are on medication.”

Just as the cholesterol and blood pressure guidelines stress lifestyle modification, Watson said she emphasizes the importance of diet and physical activity when counseling patients.

“Lifestyle has to be the foundation of prevention for any disease,” she said. “I always say the hardest part of my job is trying to change behaviors. That’s why we started the UCLA Teen Heart Health Initiative. It’s much easier to get down good habits young than to break bad habits when you’re older.”  

[Patients] feel like they’re ‘protected’ from the little cheats now that they are on medication. Karol Watson

For Parag Joshi, MD (UT Southwestern Medical Center, Dallas, TX), the Finnish study’s intriguing and hypothesis-generating, but its results are tough to confirm based on the limitations of the data. “There are so many variables that aren’t measured in these data sets that could be playing a role in the findings, including biases on who was chosen to initiate on statin,” such as those who might be on a trajectory with worse lifestyle choices, he said. He also noted that smoking cessation might contribute to weight gain, with one positive development contributing to a negative one.  

Although unaware of weight gain or decreasing physical activity among patients who start medication in his practice, Joshi said they don’t specifically look for it. “Generally we are spending more time counseling on lifestyle changes/avoiding weight gain and combining those with medications to achieve a risk reduction,” he said. “Bottom line for me: effective prevention is comprehensive and not piecemeal. [We] have to continue to hammer home the message on lifestyle modifications with our patients.”

The researchers agree there are limitations to their analysis, one of which is the generalizability of the results given that it’s a relatively homogeneous sample of white public sector workers. There are also no data available on the type of counseling patients may have received when starting the medications. Nonetheless, the new data support the idea there is room for improvement when it comes to lifestyle-related risk factors in patients who have started preventive medication, they say.