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Evidence-based practice in cardiovascular nursing: reduncing risk through behavioral interventions

Before we can talk about changing behavior we need to understand the importance of promoting health and preventing cardiovascular disease, so I am first going to talk about population trends that make it imperative that we focus on prevention of not only cardiovascular disease, but on noncommunicable disease in general.

Next, I am going to talk about how we reduce cardiovascular risk and a new concept called “ideal cardiovascular health.” Then I will discuss the nursing responsibilities that all of us have in reducing the risk not only of cardiovascular disease, but also of other chronic diseases.

Finally, I will tell you about my work in adults with diabetes who have or at high risk of developing cardiovascular disease.

We know that the world is facing unprecedented population growth, having just reached 7 billion people. As you can see in this slide most of the population growth is occurring in less developed countries where population growth is in the midst of a transformation from levels of high mortality and high fertility to one of low mortality and low fertility, the so-called, Demographic Transition. This has resulted in lowered fertility and mortality and increased life expectancy with only the proportion of older adults rising.

Although there is wide geographic variability, currently, 10% of the world’s population is 60 or older. This will increase to 22% by 2050, ranging from 10% of the population in Africa to 35% in Europe. Latin America will see its elderly population almost double.

In addition the percentage of the population 80 and over is expected to grow rapidly. In 2005 this segment accounted for 1% of the population, while by 2050 it is expected to reach over 4%. World population trends have not only led to the growth of the elderly population, but will have an impact on the care of the elderly. Family support for older adults is deteriorating as with a decrease in fertility, there are fewer children to care for aging parents. Additionally, fewer workers to support the growing number of retirees has serious budget, political and health care implications. The rapid growth of the ageing population brings new challenges to deal with the provision of heath care and support of older individuals, particularly in the face of an epidemic of chronic, noncommunicable disease.

This slide depicts what demographers refer to as the feminization of aging. Although women make up half of world population, by the end of the next quarter century, they will account for more than half (54 percent) of people ages 60 and older, and 63 percent of 80 and older. This has important implications particularly for cardiovascular disease.

These are US data, but show the impact of cardiovascular disease in women, in purple on the right, with more deaths related to cardiac disease than in men.

In the last set of columns you see that at ages 75 and above, the number of myocardial infarctions is higher in women as shown in purple, than in men. People fail to underestimate the importance of cardiovascular disease in women.

Additionally, the prevalence of hypertension – an important risk factor for myocardial infarction, heart failure and stroke is higher in women than in men starting at age 55.

Here are recent data from Brazil showing mortality rates for what used to be called chronic diseases, but we now call, non-communicable diseases, and which we abbreviate as NCDs, in the first column, cardiovascular disease in the second, and then cancer, chronic respiratory disease, diabetes and other NCDs. As you can see, death rates are decreasing for CVD and chronic respiratory disease most probably as a result of tobacco control and improved access to primary care. However cancer mortality and diabetes-related mortality has not decreased over time.

Here that you can see that NCD mortality was and remains greatest in the northeast and appears to have decreased more in the south and southeast. The north and northeast, the poorest regions in Brazil have the highest mortality rates from NCDs and actually observed the largest INCREASE in diabetes-related mortality over this time period, which you can see here in the blue areas.

Here you see the Ratios of ischemic heart disease in the metropolitan area of Sao Paola indicated by MASP and overall in Brazil shown as BR. Disease rates are higher in men so the ratios of each range from 1,2 to 2,0. The ratio of male to females for Ischemic heart disease, shown in pink stayed fairly steady, while in Sao Paolo the ratio increased as you see in the dark blue. For stroke, both in Brazil in the light blue and in Sao Paolo, in orange the ratio has increased over time. We should remember, however, that stroke is the leading cause of death for women in Brazil. The main risk factor for stroke is hypertension and although there has been some improvement in control of hypertension in Brazil, control remains poor. This is certainly an area for nursing intervention! And recent data show that there has not been improvement in other risk factors for cardiovascular disease – hyperlipidemia, diabetes, smoking and obesity.

In Brazil, the prevalence of overweight doubled from 1975 to 1989 (blue to red in the first two columns) for boys and girls aged 10-19 and from 1989 to 2003 (red to grey) more than doubled in boys, while remaining high in girls. Changes in adults were similar.

Here you see changes in obesity that we showed in the previous slide, but now according to family income – males on the left and females on the right. Between 1975 to 1989 (not shown in this slide), the changes were similar for people in low and high income groups, however between 1989 and 2003 you can see that for the people in the low income groups shown in blue, the increase in the number of people who were overweight was much higher than for the people with higher incomes shown in red in both males and females.

And what about other risk factors in Brazil? These data are frorm a telephone interview of residents from Brazilian capital cities.

The World Health Organization has addressed the global epidemic of non-communicable disease in this recent publication.

Contrary to what most people believe, on a world wide basis, non-communicable diseases – cancer, diabetes, mellitus, cardiovascular disease, stroke and chronic respiratory disease – NOT infectious or communicable diseases, are the leading cause of death.

They account for 36 million deaths in 2008, or more than 63% of all 57 million deaths.

By 2030 it is estimated that they will account for 7/10 deaths globally.

The burden of these disease is greatest in low and middle income countries where at least 80% of these deaths occur.

It is important to note that cardiovascular diseases, not HIV/AIDs or other infectious diseases, are and will remain the leading cause of death on a worldwide basis for the forseeable future.

As you can see the projected number of death due to cardiovascular disease, shown here in the blue line at the top is projected to increase from 10.8 million in 2010 to 15.4 million in 2050. In comparison, deaths from infectious disease, shown in the grey line, are expected to decrease at a rate of about 2% per year over the next 40 years; in comparison rates of CVD will increase by 0.7% per year and 1.1% per year for cancer.

When we talk of cardiovascular disease, we more specifically mean:

Ischemic heart disease (IHD), coronary heart (CHD)/artery (CAD) – that is heart disease as a result of atherosclerosis
Hypertension (HTN)
Stroke
Heart failure (HF)
Peripheral vascular disease (PVD)

We know that the underlying disease process in cardiovascular disease is atherosclerosis and that this process begins early in childhood. This process is influenced by genetic factors, potentially modifiable cardiac risk factors and the environment. Over time changes take place in the vessel wall that can progress to gradually occlude the lumen of the blood vessel which we often see manifested in effort angina or intermittent claudication. These placques may become unstable and may rupture with an an overlying thrombosis developing which results in unstable angina or myocardial infarction, sudden death, or stroke.

The causes of the main chronic noncommunicable disease epidemics, including cardiovascular disease, are well established and well known. Importantly for us as we try to prevent these diseases through modification of risk factors, these risk factors are SIMILAR for all!

The most important modifiable risk factors seen here in the second column are:

Unhealthy diet and excessive energy intake; physical inactivity; And tobacco use.

These major modifiable risk factors, in conjunction with the non-modifiable risk factors of age and heredity, explain the majority of new events of heart disease, stroke, chronic respiratory diseases and some important cancers. These causes are expressed through the intermediate risk factors seen in the third column of raised blood pressure, raised glucose levels, abnormal blood lipids (particularly low density lipoprotein – LDL – cholesterol), and overweight (BMI ≥ 25) and obesity (BMI ≥ 30).

Importantly, the relationship between the major modifiable risk factors and the main chronic diseases are similar in all regions of the world.

Something to keep in mind, but which we are not going to talk about today is that the underlying determinants of chronic disease, however - the “causes of the causes.” Shown here in the first column they are a reflection of the major forces driving social, economic, and cultural change - globalization, urbanization, and population ageing.

As you can see, throughout the world high, as well as in Latin America, high blood pressure, followed by smoking and high cholesterol are the three risk factors that are most strongly associated with mortality from ALL causes. All 3 are amenable to lifestyle interventions.

To give you an idea of how risk factors are associated with IHD, specifically MI – heart attack - here you see 9 factors that either increase the risk of having a heart attack – those on the right or are protective, that is associated with a decreased risk, over here on the left.

These data are from the INTERHEART study which was conducted in 52 countries. Women appear in the smaller box and men in the larger. Smoking, diabetes, high blood pressure, abdominal obesity and psychosocial factors and abnormal blood lipids were associated with a 2-4 times greater likelihood of having a heart attack as compared to people who did not have these abnormalities.

Eating fruits and vegetables, exercise and moderate alcohol consumption were associated with a decreased risk. It is important to note that these effects were seen in both men and women and were seen in all regions of the world.

This suggests that solutions and approaches to prevention can be based on similar principles worldwide and hold potential to decrease the burden of CVD.

But we know that these risk factors commonly occur together – we call this “clustering” of risk factors and this slide shows you that when they do, the risk of a heart attack rises astronomically.

The first 4 are the same individual risk that we saw on the previous slide – somewhere between 2 and 4 – already quite strong.

When the first 3 are present together, the risk rises to 16 times higher; all 4 to almost 50 times great.

When you also have obesity, you risk is more than 64 times greater; psychosocial factors, over 200 times greater and all the risk factors together ore than 256 times greater.

Risk factors for stroke were studied in the same way in the INTERSTROKE study. Stroke, as you recall, was responsible for the second highest number of deaths on a worldwide basis. Unfortunately, stroke receives even less attention than IHD. However, in 74 out of 129 WHO member countries (39%) stroke mortality was GREATER than IHD – substantially higher in China, Africa and South America.

This slide shows you not the level of risk, but the amount of stroke that is due to each of the risk factors. Another way to think of this is that it is the amount of disease that would be eliminated if the risk factor were eliminated.

For example, hypertension accounts for 35% of the cases of stroke; if we eliminated hypertension, there would be 35% fewer cases of stroke.

This study confirmed the importance of hypertension in developing countries.

You can see that hypertension, ~ abdominal obesity ~ and lack of regular physical activity ~ account for the majority of stroke cases.

In comparison, for heart attack smoking,~ psychosocial factors ~ and abnormal blood lipids~ account for the majority of the cases.

Overall, the 9 risk factors in combination account for 90% of the risk of stroke and between 90 -94% of heart attack.

I hope that I have convinced you of the importance of reducing risk factors for noncommunicable disease. But how do we reduce risk? Let’s focus on cardiovascular disease. But remember that the risks for all chronic disease are similar so that by lowering levels of cardiovascular risk we will also have an impact on diabetes and cancer!

In the United States, the American Heart Association defined new goals in order to further improve CVD mortality and morbidity. By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%

Original goals for 2010 for smoking, physical activity, obesity and diabetes were not met and so are an important focus for 2020.

It is apparent that new strategies for improving cardiovascular health and preventing disease and events and deaths were necessary.

A new metric for measuring cardiovascular health was needed, along with a new and expanded emphasis on prevention, control of risk, improving quality of life and promoting health rather than focusing on treating disease.

With the focus of the new 2020 goal on cardiovascular health, the following definition of ideal cardiovascular health was developed:

Simultaneous presence of 4 favorable health behaviors: abstinence from smoking within the past year, ideal body mass index (BMI), physical activity at goal, and consumption of dietary pattern promoting CV health

Also, the simultaneous presence of 4 favorable health factors is needed to meet the definition: abstinence from smoking with past year, untreated total cholesterol < 200 mg/dL, untreated blood pressure < 120/80 mm Hg, and absence of diabetes

Lastly, the absence of clinical CVD

Smoking is extremely important, as it appears as both a behavior and a factor. So, there are a total of 7 health behaviors and health factors critical to the definition.

To meet the complete definition of ideal cardiovascular health, an individual would need to meet ideal levels of all 7 components, plus have no CVD.

For children at the ages indicated in the parentheses, criteria are:

Smoking – never tried; never smoked a whole cigarette (12-19 y of age)
BMI - < 85th percentile (2 – 19 y of age)
Physical activity - > 60 min of moderate- or vigorous intensity every day (12-19 y of age)
Healthy diet – 4-5 component (5-19 y of age); I will show you the scoring on the next slide
Total cholesterol - < 170 mg/dL (6-19 y of age)
Blood pressure - < 90th percentile (8-19 y of age)
Fasting plasma glucose - < 100 mg/dL (12-19 y of age)

Dietary goals are based upon something called the DASH diet. This stands for the Dietary Approaches to Stop Hypertension. This includes the following 5 elements:

Fruits and vegetables: > 4.5 cups per day
Fish: > two 3.5 oz servings per week (preferably oily fish)
Fiber-rich whole grains (>1.1 g fiber per 10 g of carbohydrate): > three 1-oz equivalent servings per day
Sodium: < 1500 mg per day
Sugar-sweetened beverages; < 450 kcal (36oz) per week

Other dietary factors are important, but as one of the outcomes of the 2020 goals is to monitor levels of ideal CV risk, measurement of other factors, such as trans fat are difficult, so for now only these 5 factors are being assessed.

In thinking about cardiovascular health three key concepts in health promotion and disease prevention were recognized:

The power of primordial prevention, which I will explain in a minute.
The evidence that CVD and risk factors for it often develop early in life. This is important and underscores the need for all of us as nurses, no matter what our specialty and age group that we work with, to focus on health promotion and disease prevention. The development of chronic, NCDs disease, CVD, represents the failure of prevention across the lifespan. So, midwives and pediatric nurses have great power to reduce the occurrence of chronic disease.
The appropriate balance of population-level approaches for health promotion and disease prevention and individualized high-risk approaches.

There are three types of prevention. Primary preventive strategies are aimed at preventing clinical events AFTER risk factors are present and secondary prevention is instituted AFTER a clinical event or manifestation of cardiovascular disease.

However, once adverse levels of risk factors are already present, even in young adulthood, substantial elevations in long-term and lifetime risks for CVD are unavoidable. Therefore, we must focus on PREVENTION of the risk factors themselves. This is called PRIMORDIAL PREVENTION. Primordial prevention includes adequate levels of physical activity, healthy eating, achieving and maintaining ideal body weight, and addressing psycho-social factors and familial predisposition to CVD.

And the third concept - individual versus population-based strategies.

On a population level this strategy is conceived to prevent whole societies from experiencing epidemics of risk factors. This is usually accomplished through community-based interventions or policy initiatives such as banning smoking in public places or food policy decisions about labeling or limiting sodium or fat content. I will show you an example on the next slide. At the individual level it is to prevent the development of the risk factors in the first place.

Primary prevention focuses on individuals at highest risk for disease. Screenings for blood pressure or cholesterol, even in children and adolescents can identify those at high risk and treatment may limit clinical events. We believe that reductions in CVD mortality and morbidity have resulted from this approach in terms of both primary and secondary prevention.

However, most events occur in individuals with only moderate elevations of numerous risk factors, because this is where the majority of the population lies.

Therefore, effective health promotion and disease prevention strategies in the entire population are necessary to shift the entire distribution of risk. Examples in relation to children include the use of developmentally appropriate, culturally sensitive student-level school-based interventions WITH modifications of school food and physical activity, while in adults it could involve encouraging physical activity in the workplace or making physical activity more accessible in the community.

Here is an example of a population-based strategy – In the dotted line you see the distribution of blood pressure values in a population – from a little less than 80 all the way up to 220. Targeting only those at high risk, with blood pressure over 150 is only focusing on 2.5%, a very small proportion of the population, but by aiming at population-based strategies of diet and physical activity, the distribution of the blood pressure in the entire population shifts to the left, lowering the range of blood pressure in the population to 70 – 170, and leaving a much smaller number of people at high risk.

On an individual level a comprehensive assessment of the total CVD risk profile should occur at each visit and updated on each return visit. This includes assessment of tobacco, physical activity, dietary intake, family history and physiological measures such as body mass index and blood pressure. Nurses should also obtain a multigenerational family history for CVD and risk factors; those with family history as defined as CVD at age < 55 in males and < 65 in females are considered high risk and may require lipid screening.

Lifestyle modification emphasizing normalization of weight and healthy diet and physical activity should be instituted as appropriate.

Now, I will talk about my program of research which grew out of my clinical experiences as a nurse in the emergency department, the coronary care unit and intensive care units. Even as a nursing student, I took care of many people with diabetes as I was at a very special hospital and clinic where many people with diabetes were treated. So, caring for people with diabetes has always been part of my nursing role. I saw first-hand the devastating complications of diabetes – heart disease, peripheral vascular disease and amputations, and stroke, what we call the macrovascular complications, as well as the microvascular complications – neuropathy, nephropathy and retinopathy. When I decided to go back for my doctorate, I decided, partly for convenience reasons, but also for an interest in study design and statistics, to study epidemiology. This seemed like a good fit for nursing, as epidemiologists are very concerned with the concept of ‘risk” and “high risk” just as we are in nursing – always looking for who is at risk for a complication and how to prevent it from occurring or identify and treat it early if it does occur.

I have always been interested in the heart, so the the combination of diabetes and heart disease became a very natural focus of study.

The Framingham heart study a very important study that started in the US in the 1950s and from which we learned about cardiac risk factors, first showed the importance of diabetes, along with age and gender on CVD risk. Men with DM in first set of columns have approximately twice the risk of CVD as compared to men without diabetes, in the second set of columns, in each of the 3 age categories. Women with diabetes, in the third set of columns have from 1.8 times the risk of CVD at the oldest ages, to 6.3 times the risk in the youngest age grouping. Within each age grouping women with diabetes have higher rates of CVD than MEN without diabetes. The overall risk of CVD in women with diabetes is 3 times greater than in women without diabetes. The presence of diabetes takes away the protective effect that we normally see in premenopausal women who have low rates of heart disease.

There are five major areas in which I have focused my work:

Outcomes after myocardial infarction (MI) in older adults with type 2 diabetes (T2DM)
Screening for asymptomatic (silent) heart disease in T2DM
Diabetes self-management in Black America women with type 2 diabetes with my colleague, Dr. Gail Melkus)
Multidisciplinary intervention in asymptomatic heart disease and T2DM
And most recently, looking at the prevention and management of multiple chronic conditions

My first study grew out of my experience with patient with acute myocardial infarction. We know that 1 out of 4 older adults in the US has type 2 diabetes and they are at an increased risk of dying form cardiovascular disease – 2-4 times higher than people without diabetes. After an acute myocardial infarction they were at one and a half to two times greater risk of dying.

But we did not know why they died at this increased risk. As a nurse, particularly a critical care nurse, who we should we watch more closely? Who was at higher risk?

So as part of my docotral dissertation work I looked at 30-day and 1-year mortality, along with readmission for heart failure and recurrent MI in older adults who had an acute myocardial infarction.

First, in comparing people without diabetes shown in yellow to those who had diabetes but were not on insulin, shown in blue and to those with diabetes who were taking insulin in red. You can see that both groups of people with diabetes were more likely to have a history of heart failure, chest pain (angina), chronic renal insufficiency, stroke, priori myocardial infarction and peripheral vascular disease. So, they were already at high risk before they even had the myocardial infarction!

At 30 days after the myocardial infarction, mortality was similar in those with and without diabetes, but at one year, more of the people with diabetes in blue and red – almost 25%, had died.

And they were much more likely to be re-admitted to the hospital with heart failure or another myocardial infarction.

What did I learn?

First, that rates of death, heart failure and myocardial infarction were high in elderly with diabetes and merit attention in development of strategies to improve outcomes
Next., that risk of death, heart failure and myocardial infarction were accounted for by factors that cluster with diabetes and the co-morbidities that you saw on the earlier slide – the pre-existing heart and renal disease - highlighting importance of preventive strategies and the need for focus on multifactorial risk reduction – not just blood glucose, but blood pressure and lipids.
Finally – that we as nurses could identify high-risk subjects both in the hospital and after discharge, so that we could watch them more closely and anticipate that they might have an adverse outcome.

After I finished my dissertation, I began working on a more clinically oriented project with one of my physician colleagues, who was a member of my dissertation committee.

It has long been theorized that coronary artery disease in patients with diabetes often occurs in the absence of symptoms – so called, silent, or asymptomatic ischemia. We know that even in people without diabetes that pain is the last step in what we call the “ischemic cascade” the signs and symptoms that occur when tissue suffers form reduced blood flow, and that many ischemic episodes occur without pain being present. We have also believed that the presence of cardiac neuropathy may contribute or even cause this lack of pain. We know that the sympathetic and parasympathetic nerves that innervate the heart and blood vessels are just as susceptible to neuropathy as those elsewhere in the body – such as the neuropathy that occurs in the legs – what we call peripheral neuropathy. The neuropathy that affects the heart we call cardiac autonomic neuropathy.

I worked with three physician colleagues to design a study that would identify people who had silent, asymptomatic myocardial ischemia and would also identify the risk factors for this. In addition, we followed people for 5 years to determine the development of cardiac events and to identify the factors associated with these events. We called this the Detection of Ischemia in Asymptomatic Diabetics Study – DIAD for short. We enrolled 1123 subjects, none of whom had know heart disease or any symptoms of heart disease and randomized half to undergo a cardiac stress test with nuclear imaging and the other half just to follow-up as a comparison group.

We found that 1 out of 5 people, with no known heart disease had an abnormal stress test. And who were the people who were most likely to have an abnormal stress test?

These are hazard ratios and 95% confidence intervals.

Males were 2.5 times more likely than females to have a significant defect.

And people with cardiac autonomic neuropathy were almost 6 times more likely to have an abnormal test.

Duration of diabetes had an unusual effect – those with the shortest duration of less than 3 years and those with the longest of 12 or more years had the highest risk as compared to those with an intermediate duration.

Over 5 years of follow-up the cardiac event rate was quite low – 2.9%ffor myocardial infarction or cardiac death - which is good – and 9.4% for any cardiac event, including revascularization. Over time we saw an increase in the number of medications that people were given. All of this probably contributed to the low cardiac event rate. Our most recent analyses have led us to develop a risk score for predicting who will experience a cardiac event over 5 years. For each one of these factors you calculate the number of points based on whether or not it is present or the actual level of the factor. Then you total the individual points up from all 11 factors and from this you can obtain the likelihood of having an event.

My current doctoral student, Margaret, has worked extensively with the dataset. She is both a nurse and an exercise physiologist so has an interest in physical activity.

Her analysis showed that In both men and women, being employed full time was associated with physical inactivity.

IN MEN
- Lower Education
- Being married
- Those with cardiac autonomic neuropathy and higher waist circumference
- Were at risk for no activity
IN WOMEN
- Peripheral neuropathy and pain
- And higher BMI were associated with being inactive

In another analysis, Margaret identified predictors, as measured at baseline, for physical inactivity 5 years later. Again there were differences between men and women, but certainly the presence of inactivity at baseline was a strong predictor in both – more than 3 times more likely than people who had some activity at baseline. This underscores need for nurses to assess physical activity and try to get people moving!

Because I am a nurse and interested in psychosocial factors, I studied a smaller subset of DIAD subjects, giving them a number of questionaires to assess quality of life, anxiety and depression and a number of other factors.

We found that:

QOL and anxiety improved when subjects discussed the result of screening with their care provider.

In looking at factors associated with control of blood glucose and cardiac risk factors, we found that there were considerable differences across factors, suggesting the need for different approaches when targeting multifactorial risk reduction.

Finally we looked at factors associated with quality of life. We found high levels of anxiety in these subjects, along with depressive symptoms. Being female, having peripheral or autonomic neuropathy, physical inactivity, higher body mass index and anxiety and depressive symptoms were all associated with poorer quality of life.

Well, all of this knowledge is good and consistent with findings from other studies, however, there has not been much intervention research that focused on both diabetes and heart disease, so my next areas of study were on an intervention aimed at multifactorial risk reduction.

I had the good fortune to work with my friend and colleague, Dr. Gail Melkus, who is a specialist in diabetes care and who now directs our Research Center at NYU. She had been working on an intervention in American Black women with diabetes and I joined with her, bringing in a focus on cardiovascular disease.

We designed two small pilot studies expanding the intervention and tested it in older adults who were either at high risk of heart disease or actually had heart problems.

The behavioral intervention included both education and coping skills training, along with telephone follow-up after the classes. We used a technique called motivational interviewing in providing support for increasing levels of physical activity and the the other behaviors. Everyone was seen by a psychologist and had an individual session with an exercise physiologist. We instructed subjects how to use a pedometer as an aim was to increase the number of “steps” that they took each day.

We based our work on several theoretical frameworks. One was self-determination theory. In this theory, autonomous motivation whereby people experience a sense of volition, self-initiation and personal endorsement of the behavior as opposed to controlled behavior, where people feel pressured to behave in some way by some interpersonal or intra-psychic force, is expected to result in long-term adherence to a behavior.

Significant others understand the person’s perspective, acknowledge their feelings, offer choices, and provide relevant information. The person will develop and maintain more autonomous motivation to the extent significant others are autonomously supportive.

So, more autonomously supportive providers, which we call patient-centered, could have significant effect on autonomous motivation and as you see in the diagram, this could increase the patient’s competence and change control of their condition to improve it.

The Transtheoretical Model of Health Behavior Change, developed by Prochaska and colleagues integrates many leading theories of psychotherapy and behavior change into one model that describes behavior change unfolding through a series of stages occurring over time, rather than the single event of “quitting.” Processes of change, in the orange boxes, are activities both obvious and covert that people use to progress through the stages. They provide important guides for intervention programs since they are the stimuli that people need to apply to get from one stage to the next.

In our work we explain the process to subjects and show them this wheel.

We then ask them to rate the extent to which they are ready to change a certain behavior and we focus on the ones that they are most ready to change. The goal of the intervention is to move them along the change process, recognizing that people are more likely to be ready to change some factors more than others and that different strategies are necessary for different behaviors and for different stages in the change process.

What were our results? We showed improvements in blood glucose, blood pressure, LDL cholesterol and weight.

As well as a decrease in depressive symptoms and anxiety. An improvement in quality of life in terms of both physical and emotional function. Not shown on these slides, we also saw an improvement an increase in the number of steps walked each day.

Building on this work we are now submitting a grant using this intervention to address multiple chronic conditions – type 2 diabetes, cardiovascular disease, hypertension, obesity and depression. We know about these these conditions frequently co-occur and there is limited study of interventions aimed at addressing these conditions in combination. Patients with multiple chronic conditions are often excluded from studies. With several of our junior faculty at the College we are conducting a qualitative study of patients with cancer and diabetes or cardiovascular disease to determine the experience of managing both diseases along with conducting a systematic review of nurse-led experimental studies of self-management interventions for chronic illness. Data from 139 studies between 2000-2010 revealed that a variety of interventions have been tested in these populations and most were bundled together. Outcomes and effectiveness varied widely. For CVD self-care interventions measured effect on quality of life with mixed results that lacked sustainability over time. Our conclusion is that currently, there is insufficient evidence to support adoption of generic chronic illness self-management guidelines. Research is needed to better understand the effect of specific intervention components of bundled interventions on outcomes with guiding conceptual frameworks. Development and testing of culturally relevant self-management interventions is also critically needed.

Much work needs to be done. Shown here are the major documents and initiatives aimed at global response to CVD. Over the past 2 decades we have learned how to reduce the risk or CVD and its complications and that CVD and chronic, NCDs are a global problem, demanding a global solution, yet the epidemic not only continues, but is escalating. Treatment and prevention efforts in developing countries are urgently needed. Nursing has a key role!