Chronic Disease and Unhealthy Habits: Behavioral Management

Overview

Lifestyle choices are associated with the development of chronic non-communicable diseases (NCDs). Centuries ago, Hippocrates emphasized the power of exercise and nutrition; he noted, “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” Over the past few decades, a bevy of research papers have supported this ancient wisdom. Among these was a 1993 study on the identification of non-genetic factors that contribute to death in the United States. McGinnis and Foege examined the literature from 1977 to 1993 and determined that 19% of all deaths were attributable to tobacco use, 14% were attributable to poor diet and physical inactivity, and 5% were attributable to alcohol consumption. Eleven years later, Mokdad and colleagues reported on statistics from the United States population from the year 2000. They pointed out that the main chronic diseases causing death in the United States were cardiac disease, cancer, stroke, and chronic respiratory disease. In addition, they highlighted the root causes of those diseases and thus, the actual causes of death; among these were behaviors (e.g., tobacco use, accounting for approximately 19% of deaths; poor diet and physical inactivity, accounting for approximately 17% of deaths; and alcohol consumption, accounting for approximately 4% of deaths). These studies and others helped to connect addictions and lifestyle choices to the development of NCDs. To address these notable behaviors, Healthy People 2020 created goals to: increase the proportion of adults who meet current National Guidelines physical activity guidelines for aerobic physical activity and for muscle-strengthening activity; decrease smoking prevalence of adults to 12%; enhance restorative sleep (70.8% of adults get sufficient sleep, defined as ≥8 hours for those aged 18 to 21 years and ≥7 hours for those aged 22 years and older, on average, during a 24-hour period); increase the proportion of adults who are at a healthy weight to 33.9% thereby decreasing the proportion of adults who are obese to 30.5%.

According to the American Psychological Association's Stress in America 2015 Survey , stress also contributes to unhealthy behaviors. Among Americans who have tried to make a lifestyle change in the past 5 years, many are still trying to lose weight (58%), reduce stress (53%), eat a healthier diet (49%), get more sleep (47%), and exercise more (45%).

The NCDs (cardiovascular diseases, chronic respiratory diseases, cancer, diabetes, arthritis and neuropsychiatric diseases) take an enormous toll, not only in terms of mortality but also in terms of disability and the ballooning of healthcare costs. For this reason, the NCDs represent the most important global health challenge of the 21st century. Lifestyle is crucial in the etiology of NCDs, and healthcare providers need to work with patients to reduce these important risk factors.

The idea that Americans have some control over their chances of acquiring a chronic condition is becoming more mainstream. The five healthy habits index is commonly used in research. These five habits include: not smoking; maintaining a body mass index (BMI) <25; eating a healthy diet with high intake of fiber, low levels of refined carbohydrates, a high ratio of polyunsaturated fat compared with saturated fat, and low intake of trans fats; drinking alcohol in moderation (two drinks or less a day for men and one drink or less a day for women); and exercising regularly (at least 20 minutes 3 times a week of aerobic exercise). Gradually, the public awareness of these healthy indices has increased. Unfortunately, over the past 20 years, changes in adherence rates to healthy habits in the United States has not changed for the better. For example: obesity levels in the United States rose from 28% to 36%; the percentage of people engaging in regular physical activity dropped from 53% to 43%; the percentage of people eating ≥5 servings of fruits and vegetables in a day decreased from 42% to 26%; adherence to all five healthy indices went down from 15.2% to 8.5%; and, adherence rates to healthy habits were not more likely in people with chronic disease (e.g., cardiac disease, high blood pressure, high cholesterol, and diabetes).

Increased awareness of healthy habits does not necessarily translate into increased adoption of healthy lifestyles. As Sir Francis Bacon stated in the 17th century, “Knowledge is power.” However, knowledge alone is not powerful enough to instill lasting behavior change.

Healthy Habits and Disease Prevention and Management

Lifestyle intervention studies have demonstrated that adopting healthy lifestyles reduces morbidity and mortality of disease. Without question, obesity is a growing health concern. Therefore, losing weight and maintaining a healthy weight at or below a BMI of 25, is a goal for many people in the United States. However, simply adding healthy habits, even if they do not alter someone's weight or BMI, is also beneficial. Matheson and colleagues examined healthy habits (e.g., being a non-smoker, consuming greater than five servings of fruit and vegetables a day, engaging in physical activity more than 12 times a month, and drinking alcohol in moderation) in people in different weight categories (normal weight, overweight, and obese). Their results demonstrated that adding healthy behaviors to people's lifestyles resulted in a significant decrease in mortality, regardless of baseline BMI. This was especially beneficial for those who were obese.

Research has shown that practicing healthy habits can reduce mortality and help people prevent chronic disease. For example, Ford and colleagues found that by adhering to four healthy lifestyle factors: never smoking, maintaining a BMI <30, being physically active for ≥3.5 hours per week, and adhering to a healthy diet (high intake of fruits, vegetables, whole-grain bread, and low meat consumption) approximately 80% of chronic diseases could be prevented. Several years later, Akesson and colleagues in Sweden, conducted a population-based prospective cohort study in Swedish men who were followed for 11 years. They concluded that by not smoking; by consuming only moderate amounts of alcohol; by following a healthy diet; by walking/bicycling for longer than 40 minutes each day; by exercising for at least 1 hour a week; and by maintaining a waist circumference <95 cm, 79% of myocardial infarctions could be avoided.

Collectively, current interventions target multiple risk factors (MRFs)—as a lifestyle change—rather than individual behaviors. Indeed, in 1982, the Multiple Risk Factor Intervention Trial, a randomized trial of a multi-factor intervention program on mortality from coronary heart disease (CHD) among high-risk men, consisted of treatment for hypertension, counseling for cigarette smoking, and dietary advice for lowering blood cholesterol levels.

Lifestyle medicine is the burgeoning area of medicine that encourages and prescribes healthy habits (e.g., regular exercise, healthy eating patterns, and stress management to treat, reverse, and prevent disease). A landmark study published in the New England Journal of Medicine randomized overweight, pre-diabetic patients into three groups: placebo, metformin, and a lifestyle intervention. The lifestyle intervention targeted losing 7% of body weight by following a diet low in calories and low in fat, as well as aiming to accumulate 150 minutes of physical activity in a week. A 16-hour curriculum covering diet, exercise, and behavior modification was also part of the lifestyle intervention. These sessions, taught by case managers, were flexible and individualized. The participants also had monthly individual group sessions that reinforced the lessons. Subjects were followed for 4 years and then evaluated to see how many of the subjects, who were all pre-diabetic, went on to develop diabetes. Compared with the placebo group, the cumulative incidence of diabetes in the metformin group was 31% less, and the cumulative incidence of diabetes in the lifestyle intervention group was 58% less than the placebo group. The lifestyle medicine intervention was more effective in helping pre-diabetic patients avoid the diagnosis of diabetes than both the placebo and the metformin group.

Our lifestyles affect our ability to manage, treat, and prevent disease through different mechanisms. One of those involves gene expression changes. Ornish and colleagues demonstrated that a 3-month intensive lifestyle intervention with a focus on exercise, stress management, and nutrition could modulate gene expression in patients with prostate cancer. This epigenetics research encourages healthcare practitioners to prioritize counseling patients on behavior change.

The effect of one component alone, specifically exercise, on health has been the subject of much research. A recent meta-analysis that examined the efficacy of exercise, compared with drug interventions, on the mortality rate of people suffering from specific chronic disease (including heart disease, chronic heart failure, stroke, and diabetes), revealed that in many cases, exercise can be as effective as medicine. Investigating the effects of exercise on mood and anxiety has also become a topic of interest in the medical literature. Several studies support the use of exercise as an adjunct treatment for depression and anxiety. In one study, researchers demonstrated that state anxiety was reduced after even one 50-minute session of aerobic or resistance training exercise at a level of 70% to 80% of maximum heart rate, in subjects with elevated anxiety levels. These studies did not recommend using exercise instead of medicine, but rather in conjunction with medications. Exercise can be prescribed in a safe and effective way. Moreover, providers who exercise are more likely to counsel their patients on exercise, and specifically, providers counsel patients on exercises that they themselves perform, such as aerobic training or strength training.

The evidence shows that adopting healthy lifestyles helps patients prevent and manage chronic disease. However, starting on, counseling in, and sustaining healthy habits is a challenge for patients and for clinicians. Specific skills and tools (such as the use of the Transtheoretical Model of Change, the 5As, motivational interviewing, positive psychology, appreciative inquiry, and goal setting) can be developed by practitioners to empower patients to adopt healthy lifestyles. There is a five-step cycle that incorporates all of these strategies and techniques and serves as a guide for providers counseling patients on lifestyle changes.

Patients often need support when seeking to stop an unhealthy behavior and start a new health-promoting behavior.

Transtheoretical Model of Change

The Transtheoretical Model of Change was developed by James Prochaska, PhD, after working for 20 years with patients who suffer from addictions. It is useful, not only as a tool for treating addictions, often in conjunction with medication, but for increasing exercise, adopting a healthy diet, and changing other behaviors. This model separates patients into categories of readiness for change, including pre-contemplation (not willing or wanting to change), contemplation (considering changing), preparation (getting ready to make a change), action, and maintenance. Recognizing the stage of change that a patient is in is the first step. Then, counseling follows according to their stage of change. This model allows providers to tailor their counseling to the needs of the patient based on their stage of change.