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How to approach your patient

Specific interventions at the individual level

This part shows cognitive behavioural methods as the effective ways to help people to adopt a healthy lifestyle. Multimodal behavioural measures are especially recommended for individuals at very high risk. These measures include promoting a healthy lifestyle through behaviour changes, including nutrition, physical activity, relaxation training, weight management, and smoking cessation programmes for resistant smokers. They help patients to cope better with illness and improve adherence and cardiovascular outcome. Psychosocial risk factors (stress, social isolation, and negative emotions) that may act as barriers against behaviour change should be addressed in tailored individual or group counselling sessions.



“Lifestyle” is usually based on long-standing behavioural patterns that are maintained by the social environment. Individual and environmental factors impede the ability to adopt a healthy lifestyle, as does complex or confusing advice from caregivers. Friendly and positive interaction enhances the individual’s ability to cope with illness and adhere to recommended lifestyle changes (“empowerment”). It is important to explore each patient’s experiences, thoughts, worries, previous knowledge and circumstances of everyday life. Individualized counselling is the basis for motivation and commitment. Decision-making should be shared between the caregiver and the patient (including also the individual’s spouse and family) [1-3]. Use of the principles of effective communication [4] will facilitate treatment and prevention of CVD.

Principles of effective communication to facilitate behavioural change
Spend enough time with the individual to create a therapeutic relationship - even a few more minutes can make a difference.
Acknowledge the individual's personal view of his/her disease and contributing factors.
Encourage expressions of worries and anxieties, concerns and self-evaluation of motivation for behaviour change and chances of success
Speak to the individual in his/her own language and be supportive of every improvement in lifestyle.
Ask questions to check that the individual has understood the advice and has any support he or she requires to follow it.
Acknowledge that changing-life-long habits can be difficult and that sunstained gradual change often more permanent than a rapid change.
Accept that individuals may need support for a long time and that repeated efforts to encourage and maintain lifestyle change may be necessary in many individuals.
Make sure that all health professionals involved provide consistent information.

Access the 2016 European Guidelines on cardiovascular disease prevention in clinical practice.

In addition, caregivers can build on cognitive behavioural strategies to assess the individual’s thoughts, attitudes and beliefs concerning the perceived ability to change behaviour, as well as the environmental context. Behavioural actions such as "motivational interviewing" increase motivation and self-efficacy [5]. Previous unsuccessful attempts often affect self-efficacy for future change. A crucial step is to help set realistic goals combined with self-monitoring of the chosen behaviour [2]. Moving forward in small, consecutive steps is key to changing long-term behaviour [2]. Communication training is important for health care professionals. The “ten strategic steps” listed in Table 9 [1]:

Ten strategic steps to facilitate behaviour change
 1. Develop a therapeutic alliance.
 2. Counsel all individuals at risk of or with manifest cardiovascular disease.
 3. Assist individuals to understand the relationship between their behaviour and health.
 4. Help individuals asses the barriers to behaviour change.
 5. Gain commitments from individuals to own their behaviour change.
 6. Involve individuals in identifying and selecting the risk factors to change.
 7. Use a combination of strategies including reinforcement of the individual's capacity for change.
 8. Design a lifestyle-modification plan.
 9. Involve other healthcare staff whenever possible.
10. Monitor progress through follow-up contact.

Access the 2016 European Guidelines on cardiovascular disease prevention in clinical practice.

Combining the knowledge and skills of caregivers (such as physicians, nurses, psychologists, experts in nutrition, cardiac rehabilitation and sports medicine) into multimodal behavioural measures can maximize preventive efforts [2,6,7].

Multimodal behavioural measures are especially recommended for individuals at very high risk [2,6,7]. These measures include promoting a healthy lifestyle through behaviour changes, including nutrition, physical activity, relaxation training, weight management and smoking cessation programmes for resistant smokers [6,7]. They help cope with the illness and improve adherence and cardiovascular outcome [8,9]. Psychosocial risk factors (stress, social isolation, and negative emotions) that may act as barriers against behaviour change should be addressed in tailored individual or group counselling sessions [6,7]. There is evidence that more extensive/longer measures lead to better long-term results with respect to behaviour change and prognosis [2]. Individuals of low socio-economic status, older age or female sex may need tailored programmes in order to meet their specific needs in terms of information and emotional support [6,10,11].

References


[1] Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FD, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WM; Authors/Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association of Preventive Cardiology. Eur Heart J. 2016 Aug 1;37(29):2315-81. doi: 10.1093/eurheartj/ehw106

[2] Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, Meininger JC, Banks J, Stuart-Shor EM, Fletcher BJ, Miller TD, Hughes S, Braun LT, Kopin LA, Berra K, Hayman LL, Ewing LJ, Ades PA, Durstine JL, Houston-Miller N, Burke LE. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation 2010;122:406 – 441.

[3] General Medical Council. Consent: patients and doctors making decisions together. Manchester, UK: General Medical Council, 2008.

[4] Martin LR, DiMatteo MR, eds. The Oxford Handbook of Health Communication, Behaviour Change, and Treatment Adherence. New York: Oxford University Press, 2014.

[5] Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic

review and meta-analysis. Br J Gen Pract 2005;55:305 – 312

[6] U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams & Wilkins, 1996.

[7] Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler AD, Schmid JP. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2010;17: 1– 17.

[8] Auer R, Gaume J, Rodondi N, Cornuz J, Ghali WA. Efficacy of in-hospital multidimensional interventions of secondary prevention after acute coronary syndrome: a systematic review and meta-analysis. Circulation 2008;117:3109 – 3117.

[9] Janssen V, De Gucht V, Dusseldorp E, Maes S. Lifestyle modification programmes for patients with coronary heart disease: a systematic review and meta-analysis of randomized controlled trials. Eur J Prev Cardiol 2013;20:620–640.

[10] Hazelton G, Williams JW, Wakefield J, Perlman A, Kraus WE, Wolever RQ. Psychosocial benefits of cardiac rehabilitation among women compared with men. J Cardiopulm Rehab Prev 2014;34:21–28. 241. Burell G, Granlund B. Women’s hearts need special treatment. Int J Bbehav Med 2002;9:228–242

[11] Burell G, Granlund B. Women’s hearts need special treatment. Int J Bbehav Med 2002;9:228–242.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.

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