ORIGINAL ARTICLE
Multidisciplinary structured lifestyle
intervention reduces the estimated risk
of
cardiovascular morbidity and mortality R.L.H. Sprangers, F. Stam, H.E.C. Smid, C.D.A. Stehouwer, I.M. Hellemans
Background. Current guidelines for prevention and treatment of cardiovascular disease (CVD) emphasise the importance of a healthy lifestyle. However, successful lifestyle intervention is proving to be a challenge for healthcare professionals. Objectives. Evaluation of the effect of lifestyle intervention on cardiovascular risk factors, on reaching treatment targets and on the esimated risk of cardiovascular morbidity and mortality. Methods. The effect of a six-month multidisciplinary structured lifestyle intervention programme was assessed in 186 patients with and without a history of CVD. Results. Multidisciplinary structured lifestyle intervention reduced the estimated ten-year risk of cardiovascular morbidity and mortality. The relative risk reduction was similar in patients with and without a history of CVD, the absolute risk reduction was higher in patients with a history of CVD. In both groups blood pressure and body weight decreased, and the maximal work rate and maximal oxygen uptake increased significantly. Blood levels of total cholesterol and cholesterol/HDL ratio decreased significantly in patients with a history of CVD. In addition, target levels for blood pressure and physical fitness were more frequently reached in both patient groups. Conclusion. Multidisciplinary structured lifestyle R.LH. Sprangers H.E.C. Smid I.M. Hllemans Alant Cardio, Amsterdam F. Stan Department of Intemal Medicine, VU University Medical Centre, Amsterdam Alant Cardio, Amsterdam
C.D.A Stahouwer Department of Intemal Medicine, VU University Medical Centre, Amsterdam/Academic Hospital Maastricht
Correspondence to: R.L.H. Sprangers Alant Cardio, P0 Box 71934, 1008 EC Amsterdam E-mail: [email protected]
Nedthends Heart Journal, Volume 12, Number 10, October 2004
intervention had beneficial effects on cardiovascular risk factors. Relative risk reduction was similar in patients with and without evidence of cardiovascular disease. Follow-up is needed to see how well these effects can be maintained. (Neth HeartJ2004;12:443-9.) Key words: cardiovascular disease, cardiovascular risk, lifestyle intervention, prevention, risk factor, treatment target
Cardiovascular disease (CVD) is, with a contribution of 35%, the main cause of mortality in the Netherlands.' International and national guidelines for prevention and treatment ofcardiovascular disease emphasise the importance of lifestyle intervention and multifactorial risk factor treatment.2 The EUROASPIRE II survey demonstrated a considerable potential to reduce coronary morbidity and mortality through lifestyle intervention and risk factor management in Europe.3 Between 1995 and 2000 the prevalence of obesity increased from 25 to 33% and the prevalence of reported diabetes mellitus increased from 17 to 22% in the group ofpatients with CVD. Prevalence of hypertension remained high at 60%, despite an increase in the use of blood pressure lowering medication. These developments are probably due to adverse lifestyle trends.4 The beneficial effect of physical activity on primary and secondary prevention is well documented.' There is convincing evidence that the combination of regular exercise combined with interventions aimed at lifestyle changes reduces the incidence of recurrent cardiovascular events. 6T7 effect of lifestyle modification on blood pressure in hypertensive patients is quantitatively similar to that of pharmacological treatment.8 Several randomised clinical trials have shown that lifestyle interventions were associated with a 60% reduction in the incidence of type 2 diabetes mellitus in overweight high-risk patients.9 A targetdriven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes mellitus and microalbuminuria reduced the risk of cardiovascular and microvascular events by about
4=43
Multidisciplinary structured lifestyle intervention reduces the estimated nsk of cardiovascular morbidity and mortality
50%.1O The Lyon Heart Study showed a 70% reduction in recurrent myocardial infarction and dfeath as the result,of a Mediterranean alpha-7i.o,ei.c acid-rich diet." Nowadays, there is an increa ed iuierest in multidisciplinary structured lifestyle prones for adult
CVD patients with multiple ri factors'2"13 who. are weXl
aware of the risk of their ounheithy lifestyle, but. are often not capable of changing their lifestyle on their own.' To support patients at riskof CVD to improve their lifestyle, we developed a multidisciplinary structured lifestyle programme. In the present study we evaluated the programme with respect to the estimated risk reduction of cardiovascular morbidity and mortality, the effect on achieving treatment targets and the effect on cardiovascular risk profile.
Jlethods Setting The lifestyle programme was developed by a team consisting of a physiotherapist, sports physician, cardiologist, dietician, psychologist and internist. The programme was offered in a,specialised outpatient clinic. Patients had to be referred by a physician in order to get compensation from their health insurance company, leaving a small financial contnbution for the patients who choose to participate in the programme. Indications and
pQqntrinqications
Patients had to be 18 years or older and have at least one primary lifestyle related risk factor (smoking, overweight, physical inactivity) and one additional risk factor (manifestation ofCVID family history of CVD, hypertension, dislipidaemia Qr diabetes mellitus). Excluded from participation to te programme were patients who were unable to climb Ia fligt of stairs or to communicate in the Dutch language and those who had unstable CVD, systolic blpod pressure above 180 mmHg or diastolic blood prcssu,re above 110 mnnHg. .In addition, in diabetic patieats, a glycated haemoglobin (HbA,C) above 10,.0% or an unreated proliferative diabetic retinopathy were contra*in4ications.. Finally, comnrb,iy h4d pope stable and
J,dju,e4 jn,ot to be a ,con icaM by; their''refqring physWiin.
Qn to physical exerase l patients gave their informed consetit dta reqn,tent, aalysis and
bl4Qcc
on.
A gtandajr !+sed c,Hftecalpsoiy.$tapWdical hisltS sy m t oP m s j ¢we,?rk6 qfsr wt,,,*
measuremerits qf1 94y j,pgc h M ,$iMht, blqopd res qf1t,e !(lte ,$ 9 4tm,a, ns,*r five -
ajnteswtr rS tin1w 4l9siritn 8sr loin wrlmlqwl #f t?d sam nsMcewX¢q,w;#ylltl+s>l as
w¢)wee,enjqjj4olm,pqpt,qft4e
444
day. Fintlly, physical -examnation wasperformed by a physician and maximal workrate and maximal,oxgen uptake were measured on a (bicydeergometer. iPatints were informed about the resus Ibythe lhysiian and a written medical report focussing,on risk factors and risk behaviour was handed to the patient.and sent to the referring doctor. After six months the same diagnostic programme was repeated and,if necessary, advice on medical treatnent ofrisk -factors was given. All data were stored inan electronic patient file. Multidisciplinary structured fifestyle intervention programme The multidiscplinary structured lifestyle intervention programme had a duration of six months and was divided into two phases. In the first phase of three months, intensive groupbased (12 persons) physical training, education and counselling formed the comnerstone ofthe progranme. The exercise programme was offered twice weekly, consisting of an individualised exercise,sessionofone hour (based on the anaerobic threshold and, maximl heart rate) followed by a relaxation session of .3O minutes, adding up to 24 sessions in three months. During this period a group-counselling programme consisting of.seven sessions focussing on risk factors, physical activity, diet, motivation, stress management and training modalities was held by one of the specialised team members. During the last session, patients were instructed to design a personal training programme in order to put into practice a long-term maintenance regimen withl the use of support systems as gymnasia or other facilities oftheir choice. In the second phase of three months' the goal was to implement lifestyle changes in daily life, which was supported by a monthly exercise session led by the
physiotherapist.
Defintion of cardiovascular risk factors A history of CVID was defined as coronary heart disase (CHD). documented by a doctor, a history of cerebrovascular accident (CVA), transient ischaenic attack (IA), or peripheral vascular disease. A positive family history,of(CVID was as d if a ist-degee family member had evidence of a first manifestation Qf CVD bpefre the: 5, birthday in men and 6O6h in wqomen). Hypertension was defined as the use of antihypere ive. ,medkvatoora systolic blood prssure
above 14(,1 mm$Ig and/ora diastolic blood,pressure abpve9() mmHg. In diabtcpaients the crite wer strit;r: J1,( a4d $0 mmHIg, respectively. Iyperchqkst;rqlaniia waspresent ifpatients were on a lipidI19werng(dr1ug,or if the total gholestevol leve.l wvas wiolbetesfnllieus .1Pgh,er;p 5,,moVli,npahen,ts, ,qr (CV? Pi bqtes m4llitus was present Whcn!the ,fasti,gplMm,a glucQxse .was aboQve 7 inmol/l o.r Whn .gQpse119wi1wg ,me4ic
Multidisciplinary structured lifestyle
intervention reduces the estimated risk
of
cardiovascular morbidity and mortality R.L.H. Sprangers, F. Stam, H.E.C. Smid, C.D.A. Stehouwer, I.M. Hellemans
Background. Current guidelines for prevention and treatment of cardiovascular disease (CVD) emphasise the importance of a healthy lifestyle. However, successful lifestyle intervention is proving to be a challenge for healthcare professionals. Objectives. Evaluation of the effect of lifestyle intervention on cardiovascular risk factors, on reaching treatment targets and on the esimated risk of cardiovascular morbidity and mortality. Methods. The effect of a six-month multidisciplinary structured lifestyle intervention programme was assessed in 186 patients with and without a history of CVD. Results. Multidisciplinary structured lifestyle intervention reduced the estimated ten-year risk of cardiovascular morbidity and mortality. The relative risk reduction was similar in patients with and without a history of CVD, the absolute risk reduction was higher in patients with a history of CVD. In both groups blood pressure and body weight decreased, and the maximal work rate and maximal oxygen uptake increased significantly. Blood levels of total cholesterol and cholesterol/HDL ratio decreased significantly in patients with a history of CVD. In addition, target levels for blood pressure and physical fitness were more frequently reached in both patient groups. Conclusion. Multidisciplinary structured lifestyle R.LH. Sprangers H.E.C. Smid I.M. Hllemans Alant Cardio, Amsterdam F. Stan Department of Intemal Medicine, VU University Medical Centre, Amsterdam Alant Cardio, Amsterdam
C.D.A Stahouwer Department of Intemal Medicine, VU University Medical Centre, Amsterdam/Academic Hospital Maastricht
Correspondence to: R.L.H. Sprangers Alant Cardio, P0 Box 71934, 1008 EC Amsterdam E-mail: [email protected]
Nedthends Heart Journal, Volume 12, Number 10, October 2004
intervention had beneficial effects on cardiovascular risk factors. Relative risk reduction was similar in patients with and without evidence of cardiovascular disease. Follow-up is needed to see how well these effects can be maintained. (Neth HeartJ2004;12:443-9.) Key words: cardiovascular disease, cardiovascular risk, lifestyle intervention, prevention, risk factor, treatment target
Cardiovascular disease (CVD) is, with a contribution of 35%, the main cause of mortality in the Netherlands.' International and national guidelines for prevention and treatment ofcardiovascular disease emphasise the importance of lifestyle intervention and multifactorial risk factor treatment.2 The EUROASPIRE II survey demonstrated a considerable potential to reduce coronary morbidity and mortality through lifestyle intervention and risk factor management in Europe.3 Between 1995 and 2000 the prevalence of obesity increased from 25 to 33% and the prevalence of reported diabetes mellitus increased from 17 to 22% in the group ofpatients with CVD. Prevalence of hypertension remained high at 60%, despite an increase in the use of blood pressure lowering medication. These developments are probably due to adverse lifestyle trends.4 The beneficial effect of physical activity on primary and secondary prevention is well documented.' There is convincing evidence that the combination of regular exercise combined with interventions aimed at lifestyle changes reduces the incidence of recurrent cardiovascular events. 6T7 effect of lifestyle modification on blood pressure in hypertensive patients is quantitatively similar to that of pharmacological treatment.8 Several randomised clinical trials have shown that lifestyle interventions were associated with a 60% reduction in the incidence of type 2 diabetes mellitus in overweight high-risk patients.9 A targetdriven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes mellitus and microalbuminuria reduced the risk of cardiovascular and microvascular events by about
4=43
Multidisciplinary structured lifestyle intervention reduces the estimated nsk of cardiovascular morbidity and mortality
50%.1O The Lyon Heart Study showed a 70% reduction in recurrent myocardial infarction and dfeath as the result,of a Mediterranean alpha-7i.o,ei.c acid-rich diet." Nowadays, there is an increa ed iuierest in multidisciplinary structured lifestyle prones for adult
CVD patients with multiple ri factors'2"13 who. are weXl
aware of the risk of their ounheithy lifestyle, but. are often not capable of changing their lifestyle on their own.' To support patients at riskof CVD to improve their lifestyle, we developed a multidisciplinary structured lifestyle programme. In the present study we evaluated the programme with respect to the estimated risk reduction of cardiovascular morbidity and mortality, the effect on achieving treatment targets and the effect on cardiovascular risk profile.
Jlethods Setting The lifestyle programme was developed by a team consisting of a physiotherapist, sports physician, cardiologist, dietician, psychologist and internist. The programme was offered in a,specialised outpatient clinic. Patients had to be referred by a physician in order to get compensation from their health insurance company, leaving a small financial contnbution for the patients who choose to participate in the programme. Indications and
pQqntrinqications
Patients had to be 18 years or older and have at least one primary lifestyle related risk factor (smoking, overweight, physical inactivity) and one additional risk factor (manifestation ofCVID family history of CVD, hypertension, dislipidaemia Qr diabetes mellitus). Excluded from participation to te programme were patients who were unable to climb Ia fligt of stairs or to communicate in the Dutch language and those who had unstable CVD, systolic blpod pressure above 180 mmHg or diastolic blood prcssu,re above 110 mnnHg. .In addition, in diabetic patieats, a glycated haemoglobin (HbA,C) above 10,.0% or an unreated proliferative diabetic retinopathy were contra*in4ications.. Finally, comnrb,iy h4d pope stable and
J,dju,e4 jn,ot to be a ,con icaM by; their''refqring physWiin.
Qn to physical exerase l patients gave their informed consetit dta reqn,tent, aalysis and
bl4Qcc
on.
A gtandajr !+sed c,Hftecalpsoiy.$tapWdical hisltS sy m t oP m s j ¢we,?rk6 qfsr wt,,,*
measuremerits qf1 94y j,pgc h M ,$iMht, blqopd res qf1t,e !(lte ,$ 9 4tm,a, ns,*r five -
ajnteswtr rS tin1w 4l9siritn 8sr loin wrlmlqwl #f t?d sam nsMcewX¢q,w;#ylltl+s>l as
w¢)wee,enjqjj4olm,pqpt,qft4e
444
day. Fintlly, physical -examnation wasperformed by a physician and maximal workrate and maximal,oxgen uptake were measured on a (bicydeergometer. iPatints were informed about the resus Ibythe lhysiian and a written medical report focussing,on risk factors and risk behaviour was handed to the patient.and sent to the referring doctor. After six months the same diagnostic programme was repeated and,if necessary, advice on medical treatnent ofrisk -factors was given. All data were stored inan electronic patient file. Multidisciplinary structured fifestyle intervention programme The multidiscplinary structured lifestyle intervention programme had a duration of six months and was divided into two phases. In the first phase of three months, intensive groupbased (12 persons) physical training, education and counselling formed the comnerstone ofthe progranme. The exercise programme was offered twice weekly, consisting of an individualised exercise,sessionofone hour (based on the anaerobic threshold and, maximl heart rate) followed by a relaxation session of .3O minutes, adding up to 24 sessions in three months. During this period a group-counselling programme consisting of.seven sessions focussing on risk factors, physical activity, diet, motivation, stress management and training modalities was held by one of the specialised team members. During the last session, patients were instructed to design a personal training programme in order to put into practice a long-term maintenance regimen withl the use of support systems as gymnasia or other facilities oftheir choice. In the second phase of three months' the goal was to implement lifestyle changes in daily life, which was supported by a monthly exercise session led by the
physiotherapist.
Defintion of cardiovascular risk factors A history of CVID was defined as coronary heart disase (CHD). documented by a doctor, a history of cerebrovascular accident (CVA), transient ischaenic attack (IA), or peripheral vascular disease. A positive family history,of(CVID was as d if a ist-degee family member had evidence of a first manifestation Qf CVD bpefre the: 5, birthday in men and 6O6h in wqomen). Hypertension was defined as the use of antihypere ive. ,medkvatoora systolic blood prssure
above 14(,1 mm$Ig and/ora diastolic blood,pressure abpve9() mmHg. In diabtcpaients the crite wer strit;r: J1,( a4d $0 mmHIg, respectively. Iyperchqkst;rqlaniia waspresent ifpatients were on a lipidI19werng(dr1ug,or if the total gholestevol leve.l wvas wiolbetesfnllieus .1Pgh,er;p 5,,moVli,npahen,ts, ,qr (CV? Pi bqtes m4llitus was present Whcn!the ,fasti,gplMm,a glucQxse .was aboQve 7 inmol/l o.r Whn .gQpse119wi1wg ,me4ic
