Lifestyle Changes Or Medication?

Heinz Redwood
July 27, 2000 (Reviewed: December 13, 2002)

Introduction

The need for a preventive approach to cardiovascular disease is well recognised and has had considerable success during the past thirty years. Equally clear is the fact that prevention is far from perfect: cardiovascular disease is still at the top of the medical league table of morbidity and mortality and will probably remain there throughout the professional lifetime of today's physicians. Moreover, prevention for elderly patients still tends to be regarded as less promising, less necessary, and less evidence-based than prevention for lower age groups (see " Why do official guidelines for the prevention of cardiovascular disease stop short at the age of 80?" ).

A cascade of preventive decisions

Prevention of cardiovascular disease follows a sequence of steps leading to decisions by doctors, patients and third-party payers. These involve:

• Definition of risk factors
• Screening
• Diagnosis of condition and degree of risk
• Lifestyle changes and/or medication?
• Who pays?
• Prevention of recurrence (second heart attacks, etc)

Risk factors include smoking, obesity, excessive alcohol, unsuitable nutrition, inadequate physical exercise, high total and low-density lipoprotein, pre-existing illnesses like diabetes or kidney failure, and having already had one heart attack or other cardiovascular events.

The need for screening sounds like plain common sense, but how much screening is appropriate, at what level of diagnostic sophistication, for how many people, and at what cost? Much of the diagnosis of cardiovascular risk is based on observation and relatively simple forms of measurement (physical examination, self-reportage of smoking and drinking habits, and so on), although more expensive forms of testing (blood cholesterol, for example) are spreading. Screening and assessing risk will also become more sophisticated in step with our advancing understanding of genes as pre-disposing indicators of disease. Although the need and effectiveness of screening for hypertension is widely accepted, will health care budgets accommodate advancing technology at rising cost?

'Who pays?'

More science and technology, far from resolving the conflict over 'Who Pays?', will more likely intensify it. This conflict overshadows the entire sequence of preventive activities from screening and risk assessment to the choice between lifestyle changes and medication (or both), through to the prevention of recurrence.

Who pays for screening? For advising patients on lifestyle changes and monitoring their progress? For costly innovative drugs that can prevent subsequent and even higher costs of hospitalisation or nursing home care? For intensifying preventive activities in the effort to avert second and third heart attacks?

To what extent will healthy (or seemingly healthy) patients be willing and able to contribute financially? Will health professionals be expected to 'pay' in terms of unpaid or under-remunerated time and effort? or are insurers, employers, and taxpayers to be the source of funds for prevention in public or private sector health care systems?

Today there are few valid answers or practical proposals to end the dilemma of 'Who Pays' for preventive measures. The response to what everybody sees as the growing need to develop preventive services is twofold: large amounts of excellent research and academic advice on what ought to be done, and - in relation to the theme of this paper - the relegation of the elderly to the bottom of the pile.

The matter of 'Who Pays' for prevention is effectively set aside as inconvenient in a society that is basically attuned to paying for treatment and continues to fight over who pays for that. Moreover - let's face it - who wants to pay for preventing cardiovascular disease in the elderly when the younger prospective victims of AIDS and other infectious diseases represent a potentially more dramatic threat to public health? Any search of the Internet on the subject of Preventive Health Care will score at least 25 hits on AIDS for one on cardiovascular disease, and the elderly are rarely mentioned at all.

The sad irony of the situation is that the health care burden of infectious disease in the industrialised world is tiny compared with that of cardiovascular disease, and the cardiovascular focus is clearly on elderly patients. That is not to deny the importance of preventing infections (which, without prevention, can spread uncontrollably), but to point out that there are other, less 'popular' preventive priorities that deserve more attention than they are getting, and may in the long run have an even greater impact on public health in the ageing societies of the industrialised world.

Preventive medication

Antihypertensive drugs have become standard preventive treatment. Their safety and efficacy are proven and their adverse reactions amply documented. The physician's armamentarium of cardiovascular drugs has grown enormously since modern diuretics were first introduced in the 1950s. It now includes beta-blockers, alpha-blockers, calcium channel blockers, ACE-inhibitors and angiotensin-II antagonists. Their use as first-line or reserve therapy is specified in professional guidelines with advice on how to prescribe these drugs for elderly patients.

In addition, cholesterol-lowering drugs took a leap forward with the development of the statins, especially when improvements in cardiovascular morbidity and mortality were demonstrated in large-scale international outcome trials. Recent evidence also suggests that statins have beneficial effects on mortality in diabetics and cardiovascular patients who do not have raised levels of blood cholesterol.

It is now widely accepted that medication for hypertension 'works' and that old cardiovascular drugs are cheap. Evidence is mounting that many of the newer 'expensive' drugs are also cost-effective, although health care payers still have problems in fitting the concept of longer-term cost-effectiveness into the framework of administering short-term drug budgets. This applies particularly to European health care systems in which the public sector holds a monopoly or near-monopoly and is not obliged to compete on the quality of outcomes.

The health care partners - physicians, patients and payers - are troubled not only by the question whether to prescribe, use and pay for preventive medicine, but when to begin to do so. Professional guidelines generally state that lifestyle changes should precede medication, and that the latter should preferably begin only when it is evident that lifestyle changes are failing to deal with risk factors.

Changing lifestyles - some fallacies

This preference for improving lifestyles first is based on rational assumptions. In real life, however, such rational common sense may harbour a number of perilous fallacies. Common sense dictates that it would indeed be desirable to substitute lifestyle changes for medication or at least to postpone the need for drugs, but -

• To change one's lifestyle preventively demands a determined commitment on the part of the 'pre-patient'_..in a notoriously self-indulgent social environment.
• The more difficult the proposed change, the greater is the need for expert individual guidance from health professionals with skills in behavioural management.
• In defiance of common sense, changing lifestyles is not a cheap form of health care. Efficient performance is costly, and inefficiency is a waste of scarce resources.
• Are lifestyle strategies that involve health care expenditure cost-effective? That question can be answered with exemplary brevity: We don't know.

Whereas new drugs now have to prove that they are cost-effective, lifestyle management is blithely assumed to be 'A Good Thing' - like motherhood and apple pie - without looking too deeply into such mundane matters as performance quality, durability of outcome, or real cost.

Are primary physicians competent to counsel patients on lifestyle changes?

Doctors are far from certain about their ability to give lifestyle advice. The American Task Force 8 on preventive cardiology¹, and a French 'Health Barometer' study² have produced disturbing results with remarkable national differences:

PRIMARY CARE PHYSICIANS' COMPETENCE AS LIFESTYLE COUNSELLORS Self-estimates, USA 1995, France 1998-99

ADVICE ON	% 'COMPETENT'
	USA	FRANCE
Smoking	69	43
Diet	22	66

About two-thirds of American physicians felt competent to provide counselling to smokers, but less than half of the French sample did so. By contrast, only one-in-five American doctors regarded themselves as competent to give dietary advice, whereas two-thirds of French doctors felt able to do so. Material shortcomings in counselling competence were further displayed in the French sample with scores of 59% for physical exercise, 48% for accidents in daily life (very important for the elderly), 30% on alcohol intake, and just 18% on drug abuse.

These are self-reported estimates by professionals who are generally self-confident in matters of therapy and to whom patients normally turn for personal advice. One is tempted to conclude: when you know that you need to change your lifestyle (stop smoking, cut down drinking, lose weight) and need competent help, your doctor may not necessarily be the best source for this.

The Pitfalls Of Smoking Cessation

The relatively poor 'competence scores' on smoking, which is now unequivocally recognised as one of the prime sources of cardiovascular morbidity and mortality, prompted me to look more closely at efforts to help smokers stop smoking. For prevention of a whole galaxy of diseases, smoking is one of the most vital and most difficult test cases for lifestyle change.

"Currently, cessation clinics have little impact. When offered free by HMOs in the United States, smoking cessation clinics recruit only about 1% of subscribers who smoke (Prochaska³, 1996). In the Minnesota Heart Health project, for example, 40 million dollars was spent with five years of intervention in four communities, totalling 400,000 people. There were no significant differences between treatment and control communities not only in smoking, but also on diet, cholesterol, weight, blood pressure, and overall risks of cardiovascular disease." (Luepker et al⁴ , 1994, cited by Prochaska, ibid 1996).

Message for the Department of Shattered Illusions: we are shocked, but can anything be done?

The answer is "Yes", but not quickly or cheaply or simplistically. Prochaska's experiments demonstrated effective results when the system was adapted to the smoker, instead of demanding adaptation by the smoker to the system. In other words, different types of patients need counselling along different lines at various stages of their preparedness to stop smoking. Marked improvement can occur after 18 months of focused effort (Prochaska, op.cit. Ref. 3).

The identification of the behavioural characteristics of patients as a clue to the potential efficacy of improving hypertension control has been reported in the USA by analysing a nationally representative quota sample of 1186 adults with diagnosed hypertension. Although the study (Weir et al⁵ , 2000) was not specifically concerned with the elderly, it gives interesting clues for them, because 40% of the sample was aged 65+ (compared with 13% of the U.S. adult population).

Four behavioural groups were identified in terms of hypertension control:

A - Users of medication with healthy lifestyles (46% of 'A' were aged 65+)
B - Users of medication, good compliance, poor on lifestyles (38% were 65+)
C - Forgetful users of medication, obese, little smoking/alcohol (37% were65+)
D - Unlikely to take medication, heavy smokers, poor dieters (21% were 65+)

"Group A and B members have better health outcomes than Group C and D members".

It is worth noting that the elderly (overall 37% of Groups A-D) were over-represented in the 'good' Group A, averagely distributed in Groups B and C, and markedly under-represented in the 'bad' Group D.

In other words - and perhaps not surprisingly - although the attitudes of elderly patients with hypertension do not differ vastly from other age groups in A-C, they are far less likely to show indifference or put up active resistance to medication and lifestyle changes (Group D) than younger age groups.

Group A, for example, smoked 2.2 cigarettes per day, compared with 12.9 in Group D. In Group A, 94% expressed "confidence in ability to stop smoking (or not start)", compared with 64% in Group D. As for avoiding "foods high in fat": A - 72%, D - 27%; "confidence in ability to exercise three times a week: A -89%, D - 51%; "average non-compliance with medication": A - 4.0%, D - 7.2%; and "not taking medication is a threat to my health": A - 94%, D - 81% (Weir et al, ibid 2000).

These examples also indicate that attitudes to medication are less dramatically different between Groups A and D than attitudes to lifestyle changes. The latter, as already noted, are even more difficult to achieve than compliance with medication, and require carefully judged counselling which many doctors do not feel competent (or interested?) to give.

As a parting shot on smoking cessation, an Irish study of doctors at a teaching hospital in Dublin demonstrated that:

"Irrespective of the health of the patient, the probability of receiving advice about cigarette smoking was directly related to their age. Over 75% of patients aged 65 or younger would be offered advice. This compared with 64% of those between 66 and 75, 42% of those between 76 and 85, and only 30% of those who were older than 85". (Maguire et al⁶, 2000)

This despite the fact that the risk factors of the 65+ age group are the same as for younger patients and the likelihood that the elderly will actually be more responsive to lifestyle counselling.

It seems that there is a real need for health care systems and health professionals to respond and adapt to known behavioural patterns among their patients, and for a more balanced approach to the relationship between lifestyle changes and medication. Both are needed but, contrary to what is widely believed, medication is generally more predictable in terms of compliance and outcomes than lifestyle changes. In terms of results, lifestyle changes require levels of expertise, dedication, determination and willingness to pay that are evidently not being achieved to the required and desired degree in to-day's health care systems and by today's doctors and patients.

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