February 05, 2020
Although a heart-healthy lifestyle is potent medicine in the management of cardiovascular risk, a large Finnish study finds that many — but not all — patients forgo healthy habits after starting a statin or antihypertensive medication.
Researchers studied 41,225 public-sector workers free of cardiovascular disease at baseline who completed at least two surveys in 4-year intervals from 2000 to 2013.
Results show that body mass index (BMI) ticked up among all participants, but the average increase was larger among those starting an antihypertensive or statin medication (adjusted difference, 0.19; 95% CI, 0.16 - 0.22).
Participants who started medications were 82% more likely to become obese (adjusted odds ratio [OR], 1.82; 95% CI, 1.63 - 2.03).
Medication initiators were also more likely to cut back on physical activity (adjusted difference, –0.09 MET h/day) and were 8% more likely to become physically inactive (adjusted OR, 1.08; 95% CI, 1.01 - 1.17), regardless of their baseline activity.
"My concern when I started this study was that people would think, 'now I don't need to worry about my lifestyle because the medication will do all the work for me.' Our study supports that idea," lead author Maarit J. Korhonen, PhD, a senior researcher at the University of Turku in Finland, said in an interview.
The study is better than many that have been done before because it looks at lifestyle changes over time but, unfortunately, the results are not that surprising, Russell Luepker, MD, the Mayo Professor of Epidemiology and Community Health at the University of Minnesota in Minneapolis, told theheart.org | Medscape Cardiology.
"People who get started on medications for their increased cardiovascular risk may let other things slide some," he said. "We live in a pill culture."
The study was published today in the Journal of the American Heart Association.
On Balance, Not a Wash
Although the data provide more support for the belief that initiation of preventive medication is more likely to substitute for a healthy lifestyle than complement it, there were some positive signs.
Baseline smokers who initiated statin or antihypertensive therapy were 26% more likely to quit smoking than those who remained untreated (adjusted OR, 0.74; 95% CI, 0.64 - 0.85).
Average weekly alcohol consumption went down more among medication initiators than noninitiators (–1.85 g/wk; 95% CI, –3.67 to –0.14), although the odds of heavy drinking were similar in the two groups, the authors report.
Korhonen struggled to explain why some healthy habits were adopted and others ignored. Although smoking cessation often results in weight gain, this did not explain the increased BMI finding. Smokers who took medications and quit gained more weight than smokers who quit but were untreated.
During the study period, an intensive national public health effort took place in Finland aimed at increasing awareness of diabetes mellitus and its risk factors, including the same lifestyle factors considered in the study.
"Finnish people with hypertension have also been given information on all these lifestyle changes, and still it looks like there's this divergence," Korhonen said. "So truly I don't have a clear explanation for that."
Although frustrating for physicians, the divergence is "probably not a wash," Luepker said. "I think in the large trials of statins, some of this happens, but the drugs are more powerful."
"What this reinforces to me is that we're good at prescribing things but not very good at making people successful in changing their health behaviors, and these things are additive to the drugs."
That said, Luepker observed that 15-minute physician appointments do not lend themselves to detailed lifestyle discussions and that more support staff and insurance reimbursement are needed to enhance lifestyle-modification counseling.
It is not known whether study participants were given information or counseled on healthy lifestyles but, in general, there is a recommendation that patients see a nurse regularly, "maybe once a year," after being prescribed statins or antihypertensive medications, Korhonen said.
"I think with what has been just stated in the new US [primary prevention] guidelines, which are in line with the European ones, that some new approaches have to be found and used — cognitive-behavioral strategies and also this multidisciplinary approach," she added. "We need new ways to get the message across and support the patients."
That message also needs to take into account the patient's health literacy, Nieca Goldberg, MD, medical director of the NYU Women's Heart Program, New York City, told theheart.org | Medscape Cardiology.
"When we speak to patients, we need to figure out what that individual understands," she said. "Not everyone is the same, and every patient you see has a different level of health literacy. So we really need to tailor our messaging to the individual patient to try to figure out what it is that will motivate that patient."
When prescribing statins, Goldberg said she emphasizes the importance of diet and exercise in further reducing cholesterol and cardiovascular risk, but that medication dosage can also be a powerful motivator for some.
"I can only share what I say to my patients and I get relatively good compliance: I tell them that doing these lifestyle changes will help us keep the same dose of medicine," she said. "That seems to be helpful because people have this idea in their mind that getting a higher dosage is a bad thing."
The researchers used pharmacy-claims data to determine medication use but did not have information on participants' diet, blood pressure, or cholesterol levels. Other limitations are the generalizability of the results outside the relatively homogenous sample of mostly white, female workers (84%; mean age, 52 years), Korhonen said.
She noted that the results are in line with previous evidence that comes mostly from cross-sectional studies looking only at statins or only at antihypertensive medications, but that this is probably the largest study conducted on this topic to date that looked at both medications and is also longitudinal.
The main results did not change appreciably in sensitivity and subgroup analyses, although these analyses showed that BMI increases were more pronounced among those taking medications aged 40 to 49 years.
Participants who already had three or four unhealthy behaviors at baseline (n = 1231) were also at particular risk. Those taking preventive medications had greater increases in BMI and decreases in MET h/day than noninitiators, with no significant difference in change in average alcohol consumption or in the odds of current smoking.
"To the individuals who start these medications, I would tell them they should make an effort to continue to manage their weight, be physically active, keep alcohol consumption in moderation, and quit smoking because all these changes help them decrease their cardiovascular risk and also live a healthier life overall," Korhonen said.
The study was supported by the Academy of Finland. Korhonen received grant support from the Hospital District of Southwest Finland. Luepker and Goldberg reported having no conflicts of interest.
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