The Big Heart Disease Lie

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Many different factors influence changing patterns of morbidity, mortality, and the spread of diseases, both globally and within and between countries. Global economic forces influence health trends around the world, as do demographic changes related to population growth, ageing, and social patterns. More locally, changes in people's living and working environments and other settings, where individuals' health is more directly affected, also play a crucial role. An impressive amount of epidemiological evidence collected over the past 50 years has identified the influence of a number of key behavioral determinants and lifestyle risk factors on social, physical, and mental health.

A small subset of these health behaviors are particularly critical lifestyle risk factors for non-communicable chronic diseases, their management and progression (WHO, 2005). Physical inactivity, unhealthy eating, alcohol consumption, and tobacco use are the primary behavioral risk factors for cardiovascular and respiratory disease. These potentially modifiable behavioral risk factors are contributing to an ever increasing global burden of disease and rising health-care costs in most countries (WHO, 2005). Indeed, tobacco use is a risk factor for

Department of Epidemiology and Preventive Medicine, Monash University, 89 Commercial Rd, Melbourne, VIC 3004, Australia e-mail: [email protected]

six of the eight leading causes of death in the world and is the single most preventable cause of death today (WHO, 2008). Sedentary lifestyle and poor nutrition are major risk factors for overweight and obesity which lead to adverse metabolic changes including increases in blood pressure, unfavorable cholesterol levels, and increased resistance to insulin, which then lead to an increased risk of coronary heart disease (CHD), stroke, diabetes mellitus, and several forms of cancer (WHO, 2002). The World Health Organization's 2002 World Health Report indicated that physical inactivity alone now causes about 15% of the disease burden associated with diabetes, heart disease, and some cancers (WHO, 2002). Additionally, poor nutrition, including low intake of fruit and vegetables and high intake of (saturated) fat, sugar, and salt, is responsible for almost 3 million deaths a year due to the resulting development of cardiovascular disease (CVD) and cancer (WHO, 2002).

Ischemic heart disease and cerebrovascular disease were identified as the global leading causes of mortality, accounting for 42.4% of all deaths across the world in 2000 (WHO, 2001). It has been estimated that without action to address the underlying lifestyle risk factors, non-communicable chronic diseases will account for a further 17% of deaths globally by 2015 (WHO, 2005). Of even greater concern is the fact that while unhealthy lifestyle behaviors and their associated diseases are already at high levels in developed countries, they are now also becoming increasingly prevalent in developing countries as well (WHO, 2002).

A. Steptoe (ed.), Handbook of Behavioral Medicine, DOI 10.1007/978-0-387-09488-5_62, © Springer Science+Business Media, LLC 2G10

In summary, the established links between behavior and health are now very considerable. Research in a number of different chronic diseases has now clearly established the complex interplay that occurs between behavioral, psychological, social, and environmental factors and how collectively all of these factors can have an important bearing on disease progression, quality of life, and health outcomes (WHO, 2002). Addressing key lifestyle risk factors can lead to improved health (primary prevention), reduced risk of disease (secondary prevention), and improved health outcomes (tertiary prevention). While a substantial evidence base has established the effectiveness of lifestyle change approaches as an important component of smoking cessation (Barth et al, 2008; DiClemente et al, 1991), chronic disease prevention and management through lifestyle changes related to diet and physical activity are not nearly as well developed (Yach et al, 2005). For example, the first US Surgeon General's Report on Smoking and Health was published in 1964 (US Department of Health and Human Services, 1964), but the first US Surgeon General's Reports on Nutrition (US Department of Health and Human Services, 1988, 1996) and on Physical Activity (US Department of Health and Human Services, 1988, 1996) were not published until over 20 years later, in 1988 and 1996, respectively. Furthermore, a number of self-care behaviors such as regular blood glucose monitoring and adherence to treatment regimens that involve the taking of multiple medications and also complex clinical care are also often required for management of chronic diseases such as heart disease and diabetes. Therefore, it is important to establish the effectiveness of approaches targeting self-care behaviors either alone or in combination with other lifestyle behaviors.

This chapter reviews the existing evidence base for behavioral interventions in relation to the prevention and management of chronic disease. Our focus is on key lifestyle and self-care behaviors - dietary behaviors, exercise, smoking, and disease management behaviors - that are causally linked to circulatory and commonly related conditions, including CVD, diabetes, and respiratory conditions. The review is conducted in three steps. First, we consider the evidence for the effectiveness for behavioral interventions by considering the systematic reviews in this field. Next, we supplement these findings with issues and findings from relevant narrative reviews. Finally, we discuss the implications of these findings for future research and practice in the field.

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