Goal-Setting and Follow-Up Key to Lasting Lifestyle Changes

A mix of counseling, self-monitoring and following up with a health care provider is the ideal means of getting patients to make lifestyle changes that will last, and lower their risk of heart disease, researchers say.

In a new scientific statement from the American Heart Association, researchers recommended goal-setting and establishing a plan for follow-up as among the most important components of successful and durable lifestyle interventions, according to Nancy T. Artinian, a registered nurse at the Wayne State University College of Nursing in Detroit, and her colleagues.

The scientific statement was published in Circulation: Journal of the American Heart Association.

"We need to do a better job finding ways to help people not only change their behaviors, but maintain them over a lifetime," Artinian said in a statement.

"As health care providers, we're pretty good at saying that you are at risk for a disease, you need to lose weight, be more physically active, and eat more fruits and vegetables," she added. "While that's easy to say, it's not easy for the person to actually translate it into their everyday life."

Behavior Changes Are Easier Said Than Done

Cardiovascular disease is the leading cause of death in the United States, claiming 2,300 lives every day -- one death every 38 seconds -- despite evidence that even modest lifestyle changes can substantially reduce cardiovascular morbidity and mortality, according to the American Heart Association.

Many people make lifestyle changes, such as changing their eating habits, but do not maintain them over time.

But physicians assert that it's not just patient behaviorr at fault. Lack of insurance coverage of effective programs remains a challenge as well.

"The immediate issue is to provide reimbursement to providers, especially physicians, for behavioral counseling around lifestyle changes," Dr. Gbenga Ogedegbe, director of the Center for Healthful Behavior Change at New York University, wrote in an e-mail. "This will encourage providers to engage their patients more often."

In Need of Specific and Attainable Goals

So in a search for strategies proven to produce lasting change, the researchers reviewed 74 studies published between January 1997 and May 2007.

At the top of the list, with level-A evidence to support their use, are cognitive-behavioral strategies such as goal-setting and feedback.

Goals should be specific and attainable, the researchers wrote. Self-monitoring, such as the use of food diaries, is a well-researched tool that aids maintenance. There should also be a plan for the duration of patient follow-up with a health care provider to reinforce goals and monitor progress.

Peer-based support is another key component to lasting change, the researchers added.

Individual strategies for lifestyle change should assist with goal-setting and the creation of a realistic plan to achieve those goals. Group strategies should involve the creation of physical activity programs and maximizing peer support.

Community-Based Changes May be More Effective

The American Heart Association noted that studies show that addressing the cultural and social variables that influence behavioral change leads to improved adherence. For instance, researchers should identify a setting to minimize any barriers to accessing the intervention.

Also, in certain communities, it may be beneficial to deliver interventions through a lay health adviser rather than a health professional.

Intervention programs should also be culturally sensitive, Artinian and colleagues wrote.

The researchers also cautioned that persistent barriers remain to successful lifestyle change interventions. These barriers include: low-income neighborhoods with few options for buying affordable and healthful foods, limited options for physical activity (e.g., unsafe streets for walking and lack of public parks), and patient doubts about whether lifestyle changes will result in desired outcomes, as well as lack of reimbursement for lifestyle change interventions and provider time restraints for follow-up.

The American Heart Association called for policy changes on the local and national level, in workplaces, and by the health care and insurance industries to foster healthy lifestyles that reduce cardiovascular risk.

Doctors Maybe Be Embarrassed

Dr. Cam Patterson, chief of cardiology at the University of North Carolina at Chapel Hill, wrote in an e-mail that physicians aren't surprised by the recommendations, but "maybe we are a little bit embarrassed that we don't already have a plan in place in our practices to meet these obvious needs."

"Until we have fundamental changes in reimbursements to health care providers for longitudinal services that deal with diet, diabetes care, exercise, and other risk factors that can be controlled if we take the time, this message is going to fall on deaf ears," Patterson said.

But, he added, if there is "effective health,care reform that incentivizes everyone -- patients, providers, and employers -- to take heart risk reduction seriously, it will pay for itself many times over."