‘Sizeable’ Segment of Public, Even When at High CVD Risk, Feels No Need to Improve Health

Many people at high risk for cardiovascular events feel no urgent need to alter their existing lifestyle to improve their physical health, according to the results of a new study. In fact, one in five individuals at the highest risk—those with more than five potentially modifiable risks factors, such as hypertension and diabetes mellitus—perceive no need for positive lifestyle changes.

“As physicians we spend a substantial amount of time trying to find ways to effectively change patient behaviors,” Daniel Ramirez, MD (University of Ottawa Heart Institute, Canada), told TCTMD. “I think if we’re really honest with ourselves, we don’t really know how to best to do that.”

For the researchers, the study highlights the complexity of getting patients to adopt heart-healthy habits. They note that simply because a patient is aware of potentially modifiable risk factors, the perceived need to change doesn’t always follow. Ramirez said that while physicians can discuss comorbidities and risk factors with their patients, the urgency to make positive changes might not be there for people who live with these chronic conditions.

The study, published May 3, 2017, in the Journal of the American Heart Association, included 45,443 participants from six provinces who completed the Canadian Community Health Survey on their physical health. Participants self-reported the presence or absence of eight potentially modifiable risk factors first identified in the INTERHEART study: smoking status, obesity (body mass index was calculated based on height and weight), low physical activity levels, high psychological stress, hypertension, diabetes mellitus, low fruit/vegetable consumption, and excessive alcohol intake (cholesterol levels were not available).

The main outcome of interest was the answer to this question: do you think there is anything you should do to improve your physical health? In total, 73.6% of participants reported a need for improvement, with 81.1% stating they planned to take action within the upcoming year to improve their health.

In a multivariate analysis, the presence of each modifiable risk factor was associated with a greater likelihood the patient would perceive the need to improve his or her physical health (prevalence ratio 1.06; 95% CI 1.05-1.07). Younger participants and visible minorities were less likely to feel a need to change when compared with older participants and white subjects.

Overall, 33.2% and 27.1% of participants with one or two potentially modifiable risk factors, respectively, perceived no need to improve their physical health. Similarly, for those with three or four risk factors, 23.3% and 19.4%, respectively, also felt no need to improve their health. For those at the highest risk—those with five or more risk factors—17.7% did not perceive a need for changes.

Smoking, obesity, and low levels of physical activity were most strongly associated with a need to change lifestyle habits. In contrast, hypertension, diabetes, and excessive alcohol consumption were not associated with a perceived need to improve physical health.

Not Even at Contemplation Stage

Michael Miller, MD (University of Maryland School of Medicine, Baltimore), who was not involved in the study, noted that while hypertension and diabetes were not associated with a need to change, many of the participants might have thought that in order to address these conditions, exercise, losing weight, and improved dietary habits needed to be incorporated into their lifestyle.

“After all, that is what many of us consistently preach to our patients,” Miller told TCTMD. “A more sobering possibility is that respondents perceive that once a diagnosis of hypertension or diabetes is made, then the process becomes irreversible and medications take precedent. Consequently, this might help to explain why some of our patients with hypertension and type 2 diabetes mellitus remain poorly compliant to lifestyle measures.”

To TCTMD, Ramirez said the data do not allow them to tease out responses from patients taking hypertensive or antidiabetic medications to determine if they felt differently about the need for lifestyle changes compared with those not on such drugs. With a prescription for therapy, it’s possible patients might not feel a need to make lifestyle changes even though they would still stand to benefit by improving their physical health, he said. 

For high-risk patients with multiple risk factors, Ramirez said physicians might assume they would be particularly motivated to change, but this is not necessarily true. Some might even become accustomed to living with comorbidities and other conditions. “We’re finding that four out of five patients want to change, which is good. But even for one out of five, at least how the question was worded in our survey, there’s at least a suggestion they don’t feel that need, they don’t feel that urgency,” he told TCTMD.

This perceived need for change is critically important before any significant modifications can occur. “If they’re not even at that contemplation stage, the likelihood of us succeeding by simply reciting facts is small,” said Ramirez.

In terms of barriers to positive health changes, frequently cited issues were lack of willpower, discipline, work, and family responsibilities, while cost, stress, lack of resources, and lack of transportation did not present a challenge to this particular subject group. Ramirez said behavior change remains a complex issue requiring a lot further study.  

“I think we need to go back to the basics about a patient’s health perceptions,” he said. “What do they actually think of their disease? How do they live with it day-to-day? And why does it have a large impact on some but not others?”