1. Adherence to Lifestyle Guidelines: Barriers to Reaching 2020 Goals? Lora E. Burke, PhD, MPH, FAHA, FAAN University of Pittsburgh American Heart Association NPAM/EPI Spring Meeting March 2011

2. No Conflicts to Disclose Research is supported by NIH

3. AHA 2020 IMPACT GOALS By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.

4. Healthy Lifestyle Healthy diet energy balanced and nutrient dense fruits and vegetables high-fiber whole grains, low-fat milk, seafood reduced added sugars, solid fats, refined grains and sodium Physical activity (PA) 150 min/wk of moderate (MPA) 75 min vigorous (VPA), or combination of two

5. Shifts in Food Environment 1970 – 2008 19702008 Average daily per capita calories (+30%) 2057 cal2674 cal Added fats and oils (+56%) 56 lbs87 lbs Added sugars & sweeteners (+15%) 119 lbs136 lbs

6. Shifts in Food Environment 1970 – 2008 Total milk beverage declined 33% Fruit juice increased 25% Carbonated soft drinks increased 20% Diet soft drinks increased 58% Regular soft drinks increased 9% Van Horn et al., 2010 Dietary Guidelines Advisory Committee

7. Dietary Intakes in Comparison to Recommended Intake Levels/Limits 2010 Dietary Guidelines Advisory Committee Report

8. Full Adherence to Heart Healthy Behaviors in US Sample 2000 BRFSS data Examined those with & without CHD Excluded those with poor physical health or activity limitations Defined fully adherent as: Diet: 5 servings F & V/day PA: MPA 5 days/wk for 30 min or VPA 3 days/wk for 20 min Smoking: Never or former smoker Miller et al., Prev Chronic Dis, 2005

9. Percentage of Respondents Adherent to Recommendations 47% 2% 4% 1% 5% 14% 10% Smoking Abstinence (76%) Fruit & Vegetable Intake (18%) Physical Activity (24%) None 18% Without Heart Disease Miller, et al. 2005

10. Percentage of Respondents Adherent to Recommendations None 16% With Heart Disease Miller, et al. 2005 48% 2% <1% 7% 12% Smoking Abstinence (80%) Fruit & Vegetable Intake (22%) Physical Activity (21%)

11. Full Adherence to Heart Healthy Behaviors in US Sample cont. Adherence rates similar to earlier BRFSS reports in 1990, 1994, and 1996 1 in 20 adherent to all 3 behaviors > high school education highest income Younger population: better adherence to PA lower adherence to diet and nonsmoking Miller et al., Prev Chronic Dis, 2005

12. Compliance with PA Guidelines for Americans, NHANES 05-06 Self-Report Data 324.5±18.6 min/wk MPA 73.6±3.9 min/wk VPA 62% met guidelines Accelerometer Data 45.1±4.6 min/wk MPA 18.6±6.6 min/wk VPA 9.6% met guidelines Tucker et al., Amer J Prev Med, 2011

13. Age-Adjusted Prevalence of Obesity in Adults Ages 20–74 by Sex and NHANES Survey Note: Obesity is defined as a BMI (body mass index) of 30.0 and higher. Source: Health, United States, 2009; NCHS. ©2010, American Heart Association, www.heart.org.

14. Note: the next 4 slides reflect the success that we achieve in weight loss through behavioral treatment and lifestyle approaches; however, the second part of the curve indicates the high rate of recidivism due to lack of sustained adherence to a healthy lifestyle. The following slide reflects adherence and how it declines over time, depicting four different behaviors. This slope occurs across several behavioral domains, from diet and exercise to medication-taking behaviors.

15. Trajectory of Weight Loss and Regain Jakicic et al., Arch Int Med 168;1550-1559, 2008

16. Wadden et al. Gastroenterology Vol. 132, No. 6, 2007 Trajectory of Weight Loss and Regain

17. Svetkey, et al., JAMA; 299(10): 1139-1148, 2008 Trajectory of Weight Loss and Regain

18. Burke et al., 2011

19. Decline in Treatment Adherence Over Time PREFER Trial Acharya, Elci, Sereika et al., 2009

20. Summary of Adherence to Healthy Lifestyle n Adherence to healthy lifestyle guidelines is far below what is needed to achieve the 2020 goals n Adherence to any Tx strategy declines over time, especially after reduced contact n Recidivism and weight regain remain significant problems in the Tx of excess weight

21. Key Barriers to Adherence to Healthy Lifestyle Access to healthy foods, recreational settings Cost Nutrition knowledge/behavioral skills to implement healthy lifestyle Time required to incorporate behavior change Motivation to change & maintain behavior in a non-supportive environment

22. Future Directions Address overweight & obesity as a chronic disorder that needs ongoing management Make BMI a vital sign Discuss weight with patients Use technology to: reach a greater portion of the population provide ongoing contact/reinforcement Prevent weight gain!

23. Call to Action Address lifestyle nonadherence at multiple levels Modify the environment Make healthy lifestyle the norm Translate study findings behavioral Tx Implement evidence-based adherence- enhancing strategies into clinical and public health practice

24. After assessing 74 studies published between 1997 and 2007, authors concluded that a combination of approaches at the patient, provider, and health-policy level yields better results than any isolated strategy.