Lifestyle change in patients with cardiovascular disease: Never too late to adopt a healthy lifestyle

Abstract

This editorial refers to ‘Long-term lifestyle change and risk of mortality and type 2 diabetes in patients with cardiovascular disease’ by Nadia E. Bonekamp et al. https://doi.org/10.1093/eurjpc/zwad316. Cardiovascular disease (CVD) remains the predominant cause of mortality and health burden worldwide, with global prevalent cases of 523 million in 2019.1 Patients with CVD face an elevated risk of mortality and type 2 diabetes compared to the general populations, highlighting the importance of identifying modifiable factors that can help mitigate or potentially eliminate the excess risk of mortality and type 2 diabetes associated with CVD. It is well known that a healthy lifestyle pattern (including, but not limited to, no smoking, limited alcohol intake, balanced diet, and regular physical activity) is of paramount importance in the prevention of CVD among general populations,2 while the potential benefits of a healthy lifestyle on the prognosis of CVD remain relatively underexplored. Furthermore, lifestyle behaviours are modifiable over the life course, especially after the diagnosis of specific conditions such as CVD.3 However, what remains less understood is the potential impact of long-term lifestyle changes on the prognosis (such as mortality and type 2 diabetes) among patients with CVD. The commented study by Nadia E. Bonekamp and colleagues takes a significant step in providing population-based evidence on the relationship between lifestyle change (both each single behaviour and the lifestyle combination) and the risk of mortality and type 2 diabetes among patients with CVD. The authors analysed the data of 2011 participants (78% were male, mean age was 57 years at baseline) from the UCC-SMART cohort who had established CVD and attended the reassessment visit. Four lifestyle behaviours—smoking, waist circumference, physical activity, and alcohol consumption—were combined, with overall lifestyle change classified as persistently healthy, improved, worsened, or persistently unhealthy. During the ∼ 10 years between baseline and reassessment visit, 75% of participants remained persistently either healthy or unhealthy, while the remaining changed their lifestyle, with 17% improved and 8% worsened. Hazard ratios (HRs) were estimated to examine the relationship between different classifications of lifestyle changes and the risk of mortality and type 2 diabetes, after adjusting for sex, age, and education level. Compared with the individuals of persistently unhealthy lifestyle, those who maintained a healthy lifestyle had almost 50% lower risk of all-cause mortality, cardiovascular mortality, and incident type 2 diabetes. It is encouraging that individuals who improved their lifestyle from unhealthy to healthy experienced similar benefits to those who consistently maintained a healthy lifestyle, even eliminated the risks attributed to the baseline unhealthy lifestyle. In contrast, although patients with a worsened lifestyle also showed lower hazard ratios than the persistently unhealthy patients, their advantages of starting with a healthy lifestyle at baseline were partially eroded. These findings hold substantial implications for public health policies. According to the results of the EUROASPIRE surveys, lifestyle modifications were more effective among individuals who had participated in a cardiac rehabilitation and prevention programme.4 Both studies suggested that CVD-related programmes should focus on promoting lifestyle changes for all participants, whether they have CVD or not. This study also examined the relationship between each lifestyle behaviour change and the aforementioned outcomes. A persistently healthy status of smoking and physical activity exhibited the strongest associations with all-cause and cardiovascular mortality, while persistently healthy waist circumference showed no impact (HR was approximately equal to 1). Conversely, for type 2 diabetes, persistently healthy waist circumference was most strongly associated with the risk, while the other three lifestyle factors showed no statistically significant effects (HR values are close to or equal to 1 with all confidence intervals covering 1). These results indicated that each lifestyle change has varying impacts on different CVD prognosis outcomes, but this does not diminish the recommendation to encourage patients to adopt all healthy lifestyle behaviours. Lifestyle changes, perhaps occurring simultaneously, may with some improved while others worsened. This study does not help to determine that single lifestyle behaviour change or specific combination change is the best pattern to reduce the overall CVD excess risks. Thus, studies based on large sample size are needed to explore the impact of lifestyle change in a specific factor level (e.g. smoking maintainer with improved physical activity) on health conditions. In addition, the authors categorized each lifestyle behaviour as a binary variable (healthy or unhealthy), further insig