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Improving cardiovascular health through healthy lifestyle behaviours: time to think beyond willpower
  1. Julio Alejandro Lamprea-Montealegre
  1. Cardiology, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Julio Alejandro Lamprea-Montealegre, Cardiology, University of California San Francisco, San Francisco, CA 94121, USA; Julio.LampreaMontealegre{at}

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There is considerable evidence demonstrating that healthy lifestyle behaviours contribute substantially to cardiovascular health. Various population-based cohort studies have consistently demonstrated their protective effect. For instance, in the Health Professionals Follow-up Study,1 62% of all coronary events observed in more than 40 000 men were found to be preventable through the optimal adherence to healthy lifestyle behaviours. In the Nurses’ Health Study,2 82% of all coronary events among 84 129 women were attributable to lack of adherence to a ‘low-risk’ pattern of behaviour, involving a healthy diet, regular exercise and abstinence from smoking. Furthermore, in over 50 000 participants pooled from four population-based studies,3 adherence to healthy behaviours was found to nearly halve the risk of coronary events among participants with high genetic predisposition for cardiovascular disease.

In accordance with this evidence, the American Heart Association’s (AHA) 2010 definition of ‘ideal cardiovascular health’ integrates the presence of four healthy behaviours: abstinence from smoking, ideal body mass index, regular physical activity and a healthy diet; alongside three ‘health factors:’ untreated total cholesterol <200 mg/dL (<5 mmol/L), untreated blood pressure <120/80 mm Hg and fasting blood glucose <100 mg/dL (<5.5 mmol/L). However, the association of the duration of being in ‘ideal cardiovascular health’ status and improved cardiovascular disease outcomes remains underexplored. Furthermore, it is not clear whether attainment of optimal lifestyle behaviours has concurrent protective benefits for other health conditions, such as chronic kidney disease, which share common risk factors with cardiovascular disease.

Cho and colleagues4 present the results of a study aimed at determining the impact of the duration spent in ideal cardiovascular health on the risk of cardiovascular and chronic kidney disease. The study leverages the Korean Genome and Epidemiology Study, a population-based cohort study of 8020 men and women aged 40–69 years in the Republic of Korea, and adapts the AHA’s definition of cardiovascular health, replacing healthy diet with abstinence from alcohol as a healthy behaviour. For each participant, a score of ideal cardiovascular health ranging from 0 to 14 was calculated at baseline and updated at each of the study’s seven follow-up visits, which occurred at 2-year intervals. Incident cardiovascular disease and chronic kidney disease were assessed in relation to time spent on ideal cardiovascular health (a score of 12–14): less than 5 years, 5–10 years or more than 10 years.

There are several important findings from this study. First, the prevalence of ideal cardiovascular health is very low. At baseline, only 0.42% of male participants and 3.38% of female participants had an ideal score in all seven components. Furthermore, only 6% of participants maintained an ideal cardiovascular health score for 5–10 years and 4% for more than 10 years. These findings are consistent with very low prevalence of ideal cardiovascular health observed in other populations. Second, sustaining an ideal cardiovascular health is associated with marked reductions in the risk of cardiovascular and chronic kidney disease. Participants who maintained an ideal cardiovascular health score for more than 10 years had a 70% relative risk reduction in the incidence of chronic kidney disease and 80% relative risk reduction in the incidence of cardiovascular disease compared with participants who attained an ideal score for less than 5 years. Finally, a trajectory of gradual decline to a suboptimal cardiovascular health score from an ideal score was more protective than a rapid decline for both cardiovascular and kidney outcomes, suggesting that the time spent in ideal cardiovascular health positively influences both cardiovascular and kidney health.

These results significantly add to our understanding of how lifestyle health behaviours and health factors contribute to cardiovascular and kidney health. They reaffirm that achieving higher rates of adherence to a healthy lifestyle in the population could bring about enormous public health benefits. They also point to the impacts of sustained healthy behaviours on cardiovascular and kidney outcomes. But a critical question remains: if the benefits are so profound, why is the attainment of a healthy lifestyle so low?

Healthcare providers, charged with treating individual patients without regard to where they live, what they do for a living or how much they earn, make countless recommendations to patients to change their behaviour. Yet, more often than not, patients return with the same unhealthy habits, often discouraged that they did not have enough ‘willpower’ to make a different choice.

This approach to changing behaviour is fundamentally flawed by the false assumption that choices made by individuals are made freely, without regard to the larger social context that enables their adoption.5 From a basic epidemiological perspective, if adoption of lifestyle behaviours was solely within an individual’s control, they would be distributed randomly in the population. Instead, unhealthy behaviours tend to cluster among people of lower socioeconomic status and in areas with higher social deprivation.6 While it is obvious that healthy behaviours are ultimately adopted by individuals, we cannot underestimate the complex social factors that influence their adoption. Practically, if someone has to work 80 hours a week to support their multigenerational household, can they reasonably be expected to squeeze in a high impact workout at the end of the day? Furthermore, if changing behaviour was simply about individual choice, interventions aimed at changing individuals’ behaviour chiefly through education would be expected to have large impacts. However, few individual-level interventions promoting behaviour change have been found to have sustained population-level impacts on behaviour.7

If it is not solely up to an individual’s choice to change behaviour, what can healthcare providers charged with treating individuals do to promote healthy lifestyles? Certainly, given the profound potential impacts of healthy lifestyle behaviours, healthcare providers must continue to encourage their adoption. The increasing recognition that social determinants of health impact all aspects of cardiovascular health is a step in the right direction. Holistic approaches to care, meaningfully integrating social workers and case managers as essential members of inpatient and outpatient care teams, can further our ability to understand and address how social factors may influence an individual’s ability to adopt healthy behaviours. In addition, health systems are increasingly investing in community programmes to address social determinants of health. In the USA alone, health systems are currently allocating approximately $2.5 billion to diverse social programmes encompassing housing, transportation, employment and food security.8 This represents a marked shift from historical approaches to health systems’ social investments, which were largely focused on providing uncompensated or subsidised care.8 These investments are an acknowledgement by health systems of their responsibility to ensure that the communities where people live and work are conducive to implementation of recommendations to adopt healthy behaviours, and should be both sustained, enhanced and thoroughly evaluated.

As the evidence suggests, healthy lifestyles are foundational to overall cardiovascular health. However, depending on willpower alone to modify individual behaviour will not bring about population-level changes. Healthcare providers must consider the social contexts and influences that underlie patients’ ability to implement changes to their behaviours outside of the clinical setting. And, our health systems must invest in creating conditions across the communities they serve that support healthy lifestyles for all.

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Ethics approval

This study does not involve human participants.



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  • Contributors JALM is the only author.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; internally peer reviewed.

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