Adherence to Lifestyle Guidelines: Barriers to Reaching 2020 Goals?

Lora E. Burke, PhD, MPH, FAHA, FAANUniversity of Pittsburgh

American Heart AssociationNPAM/EPI Spring Meeting

March 2011

No Conflicts to DiscloseResearch is supported by NIH

AHA 2020 IMPACT GOALS“By 2020, to improve the cardiovascular health of allAmericans by 20% while reducing deaths from cardiovasculardiseases and stroke by 20%.”

Healthy Lifestyle Healthy diet

energy balanced and nutrient dense fruits and vegetables high-fiber whole grains, low-fat milk, seafood reduced added sugars, solid fats, refined grains and sodium

Physical activity (PA) 150 min/wk of moderate (MPA) 75 min vigorous (VPA), or combination of two

Shifts in Food Environment 1970 – 2008

1970 2008

Average daily per capita calories (+30%)

2057 cal

2674 cal

Added fats and oils (+56%)

56 lbs 87 lbs

Added sugars & sweeteners (+15%)

119 lbs 136 lbs

Shifts in Food Environment 1970 – 2008

Total milk beverage declined 33% Fruit juice increased 25% Carbonated soft drinks increased

20% Diet soft drinks increased 58% Regular soft drinks increased 9%

Van Horn et al., 2010 Dietary Guidelines Advisory Committee

Dietary Intakes in Comparison to Recommended Intake Levels/Limits

2010 Dietary Guidelines Advisory Committee Report

Full Adherence to Heart Healthy Behaviors in US Sample

2000 BRFSS data Examined those with & without CHD Excluded those with poor physical

health or activity limitations Defined fully adherent as:

Diet: ≥ 5 servings F & V/day PA: MPA 5 days/wk for 30 min or VPA 3

days/wk for 20 min Smoking: Never or former smoker

Miller et al., Prev Chronic Dis, 2005

Percentage of Respondents Adherent to Recommendations

47%

2% 4%1%

5%

14%10%

Smoking Abstinence(76%)

Fruit & Vegetable Intake(18%)

Physical Activity

(24%)

None

18%

Without Heart DiseaseMiller, et al. 2005

Percentage of Respondents Adherent to Recommendations

None

16%

With Heart Disease Miller, et al. 2005

48%

2% 2%<1%

7%

12%12%

Smoking Abstinence(80%)

Fruit & Vegetable Intake(22%)

Physical Activity

(21%)

Full Adherence to Heart Healthy Behaviors in US Sample cont.

Adherence rates similar to earlier BRFSS reports in 1990, 1994, and 1996

1 in 20 adherent to all 3 behaviors > high school education highest income

Younger population: better adherence to PA lower adherence to diet and nonsmoking

Miller et al., Prev Chronic Dis, 2005

Compliance with PA Guidelines for Americans, NHANES ‘05-06

Self-Report Data 324.5±18.6 min/wk

MPA 73.6±3.9 min/wk VPA 62% met guidelines

Accelerometer Data

45.1±4.6 min/wk MPA

18.6±6.6 min/wk VPA

9.6% met guidelines

Tucker et al., Amer J Prev Med, 2011

Age-Adjusted Prevalence of Obesity in Adults Ages 20–74 by Sex and NHANES Survey

Note: Obesity is defined as a BMI (body mass index) of 30.0 and higher. Source: Health, United States, 2009; NCHS. ©2010, American Heart Association,

www.heart.org.

Note: the next 4 slides reflect the success that we achieve in weight loss through behavioral treatment and lifestyle approaches; however, the second part of the curve indicates the high rate of recidivism due to lack of sustained adherence to a healthy lifestyle. The following slide reflects adherence and how it declines over time, depicting four different behaviors. This slope occurs across several behavioral domains, from diet and exercise to medication-taking behaviors.

Trajectory of Weight Loss and Regain

Jakicic et al., Arch Int Med 168;1550-1559, 2008

Wadden et al. Gastroenterology Vol. 132, No. 6, 2007

Trajectory of Weight Loss and Regain

Svetkey, et al., JAMA; 299(10): 1139-1148, 2008

Trajectory of Weight Loss and Regain

Trajectory of Weight Loss and Regain

Burke et al., 2011

Decline in Treatment Adherence Over Time

PREFER Trial Acharya, Elci, Sereika et al., 2009

Summary of Adherence to Healthy Lifestyle

Adherence to healthy lifestyle guidelines is far below what is needed to achieve the 2020 goals

Adherence to any Tx strategy declines over time, especially after reduced contact

Recidivism and weight regain remain significant problems in the Tx of excess weight

Key Barriers to Adherence to Healthy Lifestyle

Access to healthy foods, recreational settings

Cost Nutrition knowledge/behavioral skills to

implement healthy lifestyle Time required to incorporate behavior

change Motivation to change & maintain

behavior in a non-supportive environment

Future Directions Address overweight & obesity as a

chronic disorder that needs ongoing management Make BMI a vital sign Discuss weight with patients

Use technology to: reach a greater portion of the population provide ongoing contact/reinforcement

Prevent weight gain!

Call to Action Address lifestyle nonadherence at

multiple levels Modify the environment Make healthy lifestyle the “norm” Translate study findings behavioral

Tx Implement evidence-based

adherence-enhancing strategies into clinical and public health practice

After assessing 74 studies published between 1997 and 2007, authors concluded that a combination of approaches at the patient, provider, and health-policy level yields better results than any isolated strategy.