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

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 insight is also required to define a more detailed lifestyle change and examine the relationship between the extent of change (e.g. improved from poor to moderate level or improved from poor to ideal level) and CVD-related outcome. Clear, standardized definitions of both single lifestyle behaviour and lifestyle combination are prerequisite for the implementation of lifestyle-related education or intervention. The American Heart Association formulated a relatively standardized cardiovascular health score (life’s simple 7) by incorporating four lifestyle behaviours and three biological factors, which substantially reduce the CVD burden.5 However, definitions of a healthy lifestyle are varied among published studies, either in which behaviours included in the combination or each behaviour. For example, Bonekamp et al. used four behaviours (smoking, waist circumference, physical activity, and alcohol consumption) to define the lifestyle, whereas Gao et al.6 used five (smoking, physical activity, diet, body mass index, and sleep duration), additionally including diet and sleep duration, both of which were associated with lower risk of CVD, mortality, and type 2 diabetes. While considering a certain number of the lifestyle combination, which lifestyle behaviours should be included remains uncertain. Another area of concern is the adherence of healthy lifestyle. Although the commented study presented a relatively high adherence rate (58%) of healthy lifestyle—adhering to three or four healthy lifestyle behaviours, a recent systematic review of lifestyle with type 2 diabetes showed that the adherence was higher to one (24%), two (35%), and three (18%) healthy lifestyle behaviours, while only 2% adhered to five behaviours.7 Increasing the number of healthy lifestyle behaviours typically results in greater health benefits, albeit with lower adherence rates as a trade-off. It is important to find a subtle equilibrium between the benefits and adherence. Additionally, certain lifestyle patterns may be more easily adhered to by certain subgroup of individuals compared to other patterns, even when both patterns have an equal number of behaviours. For instance, smokers might also have a preference for alcohol, while physically active individuals may naturally lean towards a healthier diet. Therefore, further studies could explore lifestyle patterns with a narrower range, specifically incorporating only two or three correlated behaviours, to improve adherence among individuals with specific preferences. Furthermore, as lifestyle behaviours change always influenced by multiple factors, further direction also includes assessing a wide range of potential modifiable factors that either facilitate or act as barriers to the adherence of each healthy lifestyle behaviour. In conclusion, this study provides insights into the impact of long-term lifestyle changes on CVD prognosis. It underscores the notion that, for an individual with CVD, it is never too late to adopt a healthy lifestyle. No new data were generated or analysed in support of this research.