- Email: [email protected]
Community-Based Healthy Living Interventions
Community-Based Healthy Lifestyle Interventions Kathy Berra, Barry Franklin, Catriona Jennings PII: DOI: Reference:
S0033-0620(17)30001-4 doi: 10.1016/j.pcad.2017.01.002 YPCAD 782
To appear in:
Progress in Cardiovascular Diseases
Received date: Accepted date:
2 January 2017 2 January 2017
Please cite this article as: Berra Kathy, Franklin Barry, Jennings Catriona, CommunityBased Healthy Lifestyle Interventions, Progress in Cardiovascular Diseases (2017), doi: 10.1016/j.pcad.2017.01.002
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ACCEPTED MANUSCRIPT Community-Based Healthy Lifestyle Interventions
Kathy Berra, MSN, NP, FAHA, FPCNA, FAAN, Co-Director The LifeCare Company;
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Nurse Practitioner, Cardiovascular Medicine and Coronary Interventions, Stanford Prevention
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Research Center, Stanford University School of Medicine (ret), USA
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Barry Franklin, PhD, FACSM, MACVPR, FAHA, Director, Preventive Cardiology & Cardiac Rehabilitation, William Beaumont Hospital Royal Oak, Michigan; Professor, Internal Medicine,
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Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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Catriona Jennings, PhD, FESC, Programme Leader and Senior Teaching Fellow for the MSc, PG Diploma and PG Certificate in Preventive Cardiology, Cardiovascular Specialist Research Nurse,
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Faculty of Medicine, NHLI Imperial College London, United Kingdom
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Corresponding author:
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Conflicts of Interest:None
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Kathy Berra, MSN, NP, FAHA, FPCNA, FAAN 1825 White Oak Drive Menlo Park, CA 94025 Phone: 650 722 2605 Fax: 1877 576 4182 [email protected]
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1. YMCA - Young Men’s Christian Association 2. DPP – Diabetes Prevention Program 3. ACEI-Angiotensin Converting Enzyme Inhibitor 4. ARB- Angiotensin Receptor Blocker 5. BP – Blood Pressure 6. CB HLIs - Community-based healthy lifestyle interventions 7. CHD-Coronary Heart Disease 8. CV- Cardiovascular 9. CVD - Cardiovascular Disease 10. CR - Cardiac Rehabilitation 11. CHD - Coronary Heart Disease 12. CDC - Centers for Disease Control 13. DEPLOY - Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA 14. CHWs - Community Health Workers 15. COACH - Community Outreach and Cardiovascular Health 16. FBO - Faith-based organizations 17. HTN= Hypertension 18. ICR - Intensive Cardiac Rehabilitation 19. PA –Physical Activity 20. SCORE - Systematic Cardiovascular Risk Estimation 21. T2D –Type 2 Diabetes
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Abstract
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In an environment in which most people have lifestyles that increase risk for initial or recurrent cardiovascular disease ( CVD) events, community-based healthy lifestyle initiatives are highly
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effective in providing programs, education and support to reduce associated CVD risk factors and improve outcomes. Pioneering programs, such as the Stanford Three Community and Five
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Cities studies, and the North Karelia project in Finland, served as prototypes for current
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initiatives. These include partnerships with national organizations (e.g., YMCA DPP) and faithbased programs. Training may be provided by healthcare professionals and/or community
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healthcare workers; initiatives include exercise-based and weight-reduction programs, smoking
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cessation interventions, dietary counseling and education, and medication adherence. Contemporary technologies and home-based programs provide alternatives to those who might not otherwise have access to center-based programs. Community-based initiatives, particularly those with state or national support, have the potential to enhance the delivery and effectiveness of CVD prevention at low cost. Word count: 146 of 150 permitted
Key words: Cardiovascular prevention Cardiac rehabilitation
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ACCEPTED MANUSCRIPT Cardiovascular risk factor Community healthcare
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Community-Based Healthy Lifestyle Interventions
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Lifestyle
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This review summarizes the important role of community-based healthy lifestyle interventions (CB HLIs) in the primary and secondary prevention of cardiovascular (CV) disease (CVD) and
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related efforts to recruit and enhance community involvement in these risk-reduction programs. We provide an overview of CB HLIs from research initiatives in the 1970s to ongoing trials and
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noteworthy clinical investigations of the 21st century. We also discuss the impact of European
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models, highlighting the pioneering studies of Drs. Puska, Fortmann, and Farquhar. In addition, we review the methodology, effectiveness, and efficacy of traditional and non-traditional cardiac
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interventions.
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rehabilitation (CR) programs, with specific reference to community and home-based
Rationale for CB HLIs
Following World War II, increasing evidence began to accumulate regarding the link between lifestyle risk factors and the prevalence of atherosclerotic CVD and stroke. Epidemiologic research supported the hypothesis that certain risk factors were likely to be causal, but randomized controlled trials were needed to further substantiate this relation.1 Established or conventional lifestyle risk factors include cigarette smoking, low physical activity (PA) , overweight and obesity, dyslipidemia, high blood pressure (BP), elevated blood glucose (including type 2 diabetes/T2D), and poor dietary habits, such as excess sodium, saturated fat, 4
ACCEPTED MANUSCRIPT trans fat, calories, and sugar intake, as well as inadequate consumption of fruits, vegetables, and whole grains. High levels of stress and other psychosocial modulators (e.g., depression, anxiety,
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social isolation) have also been implicated, either directly or indirectly, in the development of
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CVD.2 Interestingly, between 2003 and 2013, although CVD mortality decreased ~38%, the burden of some coronary heart disease (CHD) risk factors (e.g., obesity, T2D, physical
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inactivity) remained high.3
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The American Heart Association 2016 Heart Disease, Stroke, and Research Statistics reported that CVD remains the leading global cause of death, accounting for >17.3 million
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deaths per year, and this is expected to increase to almost 24 million by 2030. In 2013, CVD deaths accounted for 31% of all global deaths, with the highest burden found in low- to middle-
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income countries. The worldwide prevalence of stroke approximated 33 million, making it the
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second leading cause of death, immediately following CHD. Thus, the direct and indirect cost for healthcare expenditures and lost productivity resulting from CVD was estimated at $317 billion.3
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The Centers for Disease Control (CDC), in a recent review, noted that in 2010 chronic
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diseases were responsible for 7 of the top 10 causes of death, and that CVD and cancer together accounted for 48% of all deaths.4 The report listed obesity and T2D among the leading causes of disability and excess healthcare costs. Moreover, in 2011, more than half of all American adults were not exercising regularly, and 76% did not meet minimum recommendations for PA. In addition, 1 in every 5 adults (> 42 million) reported smoking cigarettes every day. More than 3200 Americans under 18 years of age smoked their first cigarette in 2012, and many of these are expected to become regular smokers. In 2010, the CDC estimated that the total costs for CVD and diagnosed T2D were $315.4 billion and $245 billion, respectively. These estimates include both direct medical costs and decreased productivity.4
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ACCEPTED MANUSCRIPT These enormous costs to society, individuals, and communities substantiate the need for CB HLIs and expanded research initiatives. The challenge is to effectively support healthy lifestyle
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interventions at the national, state, and community level. With medical advances and increased
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access to both primary and specialty care in the United States, communities hold great promise in supporting efforts to reduce CVD risk factors by implementing healthy lifestyle intervention
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programs.4,5
Community-based Healthy Lifestyle Research – Early Lessons Learned
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In 1981, Fortmann et al. reported the results of a CV health education program in 2 communities in Northern California.6 The goal was to determine whether a health education program could
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favorably modify conventional CVD risk factors. The Stanford Three Community Study used a
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comprehensive, multifactorial approach to risk factor reduction. The intervention and control cities were in a semi-rural, primarily agricultural area of northern California. A random
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sampling of men and women between 35 and 59 years of age were invited to participate in the
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baseline survey during the fall of 1972. The 2-year health education intervention was followed by a maintenance year, during which risk reduction efforts were continued. Subsequent annual surveys were repeated through 1975.6 The intervention was based on mass media health education. Although the targeted communities were separated from the control community by a range of low hills, the former shared a television station that was not accessible to the control community. Educational information was provided through television, radio, billboards, newspapers, pamphlets, cookbooks, and direct mail. The campaign was designed to be bilingual, given the ethnicity and culture of these communities. Both men and women in the intervention communities reported
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ACCEPTED MANUSCRIPT (self-report) reductions in dietary cholesterol (23% to 34%) and dietary saturated fat (25% to 30%) that were greater than those reported in the control community. Similar trends were noted
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for changes in plasma cholesterol. In the maintenance year, the beneficial changes observed in
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the second year were maintained or slightly improved. The researchers concluded that 3-year multifaceted health education delivered by mass media campaigns improved dietary practices
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and reduced plasma cholesterol. Although body weight increased in the control community, the
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researchers partially attributed this to the aging of the entire cohort during the intervention.6 Following this seminal study, Stanford researchers tested whether changes in knowledge
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about CVD risk factors might correlate with a reduction in disease prevalence. The Stanford Five-City Project, a comprehensive, low-cost project based on social learning theory derived
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from the initial Three Community Study, used social marketing methods equating to
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approximately 26 hours of exposure to risk reduction education. Following 30 to 64 months of education, improvements in plasma cholesterol levels, BP, resting pulse rate, and smoking
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cessation rates were observed in the treatment cohort. These changes resulted in decreases in
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composite total mortality risk scores (15%) and CHD risk scores (16%). The Five-City Project was 5 years in duration. Investigators concluded that low-cost CB HLIs can reach the public in various cost-effective and efficient ways and may decrease the morbidity and mortality associated with CVD.7 The North Karelia project, another seminal CB HLI, was launched in 1972, simultaneous to the Stanford Three City and Five City studies. It was undertaken to address the causes of and treatments for the extremely high rates of CVD morbidity and mortality in Finland. The emphasis was on smoking cessation, reductions in serum cholesterol, and improvements in BP. The project targeted middle-aged men, who, at that time, suffered the highest rates of CVD
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ACCEPTED MANUSCRIPT morbidity and mortality. As with the Stanford studies, investigators tested the feasibility and effectiveness of a community-based approach to risk reduction. It was hypothesized that the
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North Karelia project, if successful, could serve as an effective prototype for future CB HLIs.8
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This project was integrated into the healthcare system and social service programs. The interventions focused on “practical activities” to reduce risk factors, based on public education
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and supported by radio, posters, meetings, and media campaigns that were conducted in schools
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and places of work. Because Finland has national healthcare services, the education was incorporated into those services so as to reach individuals already receiving treatment for chronic
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medical conditions and CVD risk factors. Intervention staff included teachers, volunteer workers, and community leaders, influential members of the community who were able to
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integrate their efforts into established services.8
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Puska and colleagues reported an overall participation rate of 90% in the study population, approximating 10,000 subjects, aged 35 to 64 years. Decreases in risk factors were
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observed in both men and women, with greater relative reductions in men. Multiple regression
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analysis showed that overall mean net reductions in estimated CHD risk were 17% and 12% among men and women, respectively. The investigators concluded that this program was highly effective in reducing conventional CHD risk factors, and that additional study of CB HLIs was warranted.8 Based on the success of the North Karelia project, the National Institute for Health and Welfare in Finland, in association with the University of Eastern Finland Institute of Public Health and Clinical Nutrition, continued the population-based risk factor survey every 5 years from 1972 to 2012. The results of this CB HLI showed that during the 40-year study period, improvements in the three major risk factors assessed (cigarette smoking, serum cholesterol, and
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ACCEPTED MANUSCRIPT BP) were associated with reduced rates of CHD among men and women, 82% and 84%, respectively. The observed decrease in CVD mortality was primarily attributed to reductions in
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the three targeted risk factors.9
Community Organizations and Community-Based Healthy Lifestyle Interventions
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A well-known community-based nonprofit organization that has contributed to improved health
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in the United States is the Young Men's Christian Association (YMCA). There are approximately 2400 YMCAs across the US, serving ~22 million men, women, and children,
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regardless of age, income, ethnicity or socioeconomic background. Their focus is on healthy living and social responsibility, with particular emphasis on improved health and well-being
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through varied wellness initiatives over the past 40 years.10
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The YMCA and athenahealth recently partnered on a novel intervention that was based on the YMCA’s proven success with a diabetes prevention program (DPP), that is, the Diabetes
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Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) pilot.
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This DPP targeted adults at risk of developing T2D. DEPLOY demonstrated that well trained YMCA wellness instructors could implement a group-based educational DPP. At 6 months, greater weight loss and lower total cholesterol were found in intervention participants as compared with control subjects. This difference was maintained at 1 year.11
Working with athenahealth, in a coordinated effort with the Center for Medicare and Medicaid Innovation, the YMCA delivered the DPP to nearly 8000 participants over 3 years. Numerous other health organizations also assisted with the intervention. The YMCA worked closely with the American Diabetes Association in awareness building and the formation of
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ACCEPTED MANUSCRIPT policy changes that enabled prevention programs to be incorporated into health-care systems and community-based organizations. The CDC helped fund this program, and the American Medical
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Association partnered with the YMCA to ensure that physicians and other healthcare providers
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understood the goals of the program, enabling them to support it through referrals. In February 2016, the YMCA DPP announced that they had served over 42,000 participants at >1400 sites in
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45 states across the country, resulting in an average weight loss of 4.6% at the end of weekly
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sessions, and 5.5% at the end of the year.12
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The new partnership with athenahealth will allow the YMCA to increase the implementation of its DPP program in YMCAs across the country. Jonathan Bush, CEO of
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athenahealth, stated that "Care is moving out of the hospital and into more fiscal, convenient, and
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cost-effective venues." According to Dr. Matt Longjohn, national health officer of Y-USA, “The YMCA's DPP shows that community-integrated health, delivered outside of traditional clinical
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studies, is highly effective in delivering strong health outcomes.” He added that "the Y's mission
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to address gaps in care in order to improve outcomes while lowering costs is shared by athenahealth and is essential to un-break health care."10 The association between the YMCA and athenahealth demonstrates the ways in which collaborations between community-based and national health organizations can enhance synergies and improve the effectiveness of any given intervention.
Community health workers and CB HLIs
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ACCEPTED MANUSCRIPT The role of community health workers (CHWs) as integral contributors to the healthcare team is now increasingly accepted. CHWs, also called health navigators and promoters, contribute in
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numerous ways to CB HLIs. As active members of the community, CHWs provide trusted
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linkages with local community services. These individuals are generally bilingual, viewed as culturally sensitive to public health initiatives, and can assist with data collection and outcome
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assessments. They also serve as outreach workers to members of their community and can
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support case management.13,14 CHWs have effectively supported both cancer and CVD risk reduction programs in a cost-effective manner.14
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Community Outreach and Cardiovascular Health (COACH), a randomized controlled trial that used nurse practitioners as well as CHWs to target CVD risk reduction in urban
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community health centers, demonstrated significant positive outcomes.15 COACH enrolled 525
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patients with CVD, T2D, hypercholesterolemia, hypertension (HTN), or combinations thereof, from low-income minority populations. More than 70% of the study participants were women
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and 79% were black. The goals were to provide intensive pharmacologic and lifestyle
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management over a 12-month period, plus counseling aimed at overcoming common adherence barriers to treatment. When compared with controls, treatment subjects demonstrated significantly greater reductions in low-density lipoprotein cholesterol, triglycerides, systolic and diastolic BP, and hemoglobin A1c, as well as improved perceptions of the quality of their chronic disease care. This innovative model of care has great promise, especially for community residents who may be less able to afford or access relevant healthcare services.15 Krantz and colleagues evaluated whether an ongoing CVD risk reduction program, Colorado Heart Health Solutions, which was led by CHWs and integrated into both public health and healthcare settings, measurably reduced the population risk of CHD.16 As part of Colorado
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ACCEPTED MANUSCRIPT Health Solutions, CHWs provided point-of-service health screenings and education to medically underserved individuals in urban, rural, and frontier regions of Colorado between 2006 and 2009.
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The program was expanded to include: (1) a decision-support algorithm to provide guideline-
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based and tailored health messages; (2) assessment of participant readiness to change; (3) promotion of health behavior change utilizing motivational interviewing; (4) long-term follow-
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up for high-risk persons; (5) improved access to and navigation of medical care and community
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resources; and, (6) integration of healthcare provider educational detailing. During 2011 and 2012, 4743 participants at risk for CHD received medical or lifestyle referrals at the time of
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screening, and 698 (15%) were retested 3 or more months following baseline screening. Significant improvements in diet, weight, BP, lipids, and Framingham Risk Score were noted at
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follow-up. Phone contact with a CHW was associated with greater improvement in the
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Framingham Risk Score, further demonstrating that CHWs in public health and healthcare
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settings can improve CVD risk factors through screening and behavior change.16
Faith-based organizations (FBO) have a long history of partnering with healthcare
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providers and other social services in the community to provide health screenings, health education, and social services, such as mental health counseling and geriatric care. DeHaven et al. reviewed the relevant health literature over a decade (1990 – 2000), with specific reference to FBOs and health outcomes.17 The latter included improvements in overall health status, increased fruit and vegetable consumption, weight loss and blood pressure reduction. The authors noted that most programs focused on general health maintenance, primary prevention, cardiovascular health, and cancer. Programs were described as faith placed (health professionals used the church to test an intervention), faith based (the program is part of the church health ministry), or community programs. Of those studies that met search criteria, reported effects
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ACCEPTED MANUSCRIPT included significant reductions in cholesterol and BP, body weight, and disease symptoms, and increases in the use of mammography and breast self-examination. Over half of the programs
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compared with faith-based or collaborative interventions.17
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(52.8%) reported outcome measures, with faith-placed programs being more likely to report
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The authors suggested that for the 43 million uninsured in the United States, faith/churchbased community health interventions provide a viable approach to potentially reduce morbidity
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and mortality from chronic diseases. They recommend increased collaboration between health
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professionals and FBOs focused on the evaluation of health-related activities and dissemination of health findings, placing a greater emphasis on the effectiveness of the interventions, as
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opposed to their efficacy, and paying greater attention to building relationships with racially and ethnically diverse communities.17 Church-based health-care activities are increasingly important
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in supporting underserved and aging populations in the U.S.
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ACCEPTED MANUSCRIPT Translating Research into Community-Based Practice EUROACTION was a pioneering research trial that evaluated a hospital, clinic, and
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community-based nurse-coordinated multidisciplinary, family-based CVD prevention program.
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EUROACTION included patients hospitalized with CHD and their partners and high-risk patients and their partners from general practices in 8 countries across Europe, including the
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United Kingdom. At the end of 1 year, EUROACTION achieved clinically meaningful
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multifactorial risk reduction across most variables for those assigned to the intervention group. Significant improvements in diet and physical activity were noted in both patients and their
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partners. These lifestyle changes were believed to confer the reductions found in CVD risk.18 MyAction for Our Hearts was a United Kingdom initiative, developed for the National
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Health Service and based on the EUROACTION model. It addressed multifactorial risk
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reduction in patients with CHD and high-risk adults in a community setting. Spouses, partners, and family members were also invited to participate in the intervention, in order to create an
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environment where social support may favorably contribute to the outcomes achieved. The
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MyAction interventions were based on behavior change strategy and individual goal setting and planning (Fig. 1).19 The intervention resulted in significant adherence to the Mediterranean diet, and heightened levels of physical activity as well as increases in measured functional capacity. Increased prescribed medications for CVD risk reduction and improved quality of life were reported in the intervention group compared with the controls.19 MyAction was also evaluated at the Croí Institute in Galway, Ireland.20 This communitybased primary prevention initiative included a 16-week intensive risk-reduction program with follow-up at 1 year. The study included men and women >40 years of age at increased risk of CVD (assessed by Systematic Cardiovascular Risk Estimation [SCORE] evaluation of ≥5%) and
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ACCEPTED MANUSCRIPT patients with newly diagnosed T2D with 2 additional risk factors (e.g., dyslipidemia, HTN, or smoking). Adherence to the program was high, with 87.2% of participants and 84.6% of partners
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completing the intervention. At 1 year, data were obtained from >90% of patients and partners.
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As with the London-based program, the Croí program reported improvements in lifestyle, measures of psychosocial health, and CVD risk factors at 16 weeks that persisted at 1 year.20
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In summary, CB HLIs, directed by healthcare professionals working with CHWs, have
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great potential to improve both health outcomes and quality of life in populations with and at high risk for CVD. The CB HLIs discussed, including the early studies, are further described in
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Table 1.
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The Role of Cardiac Rehabilitation Programs in the Community
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Exercise-based CR programs are an integral component of community-based secondary prevention interventions for CVD patients and their families. Staff include skilled medical and
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paramedical professionals trained in cardiology, nursing, CVD risk reduction, and exercise
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science, using guideline-driven therapies.21 The impact on families and communities for those who participate in CR programs is profound. Unfortunately, these outpatient interventions remain woefully underutilized,22 and, to become optimally effective, should be “rebranded and reinvigorated.”23 To this end, Sandesara et al. suggested expanding the responsibilities of CR professionals to include home- and community-based programs to manage multiple disease states, while simultaneously addressing common barriers to participation, especially in younger and older patients. In addition, the authors strongly urge CR programs to become centers of innovation by exploiting the power of mobile technology, which may be particularly helpful in home-based interventions.23
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ACCEPTED MANUSCRIPT Secondary prevention can be achieved, in part, through adherence to prescribed drug therapies, such as antiplatelet medications, beta-blockers, angiotensin-converting inhibitors
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(ACEI)/angiotensin receptor blockers (ARB), and lipid-lowering agents, that are effective in
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favorably modifying major CHD risk factors and reducing mortality in patients with CVD. However, because nonadherence to cardioprotective medications is common in clinical practice24
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and associated with a broad range of adverse outcomes,25 optimization of medication dosing,26
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and addressing prescription nonadherence should also be a high priority in secondary prevention/CR interventions.23 Aggressive lifestyle modification can be helpful in this regard,
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providing independent and additive benefits to drug-mediated reductions in CVD mortality, and a substantially lower risk of recurrent CVD events.27,28 Accordingly, community-based CR staff
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should routinely counsel their CHD patients to engage in structured exercise and increased
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lifestyle PA at moderate-to-vigorous intensities (>3 metabolic equivalents), consume a hearthealthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial
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stressors (e.g., depression, anxiety, social isolation) that may elevate CVD risk.29
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For CVD patients seeking a more aggressive lifestyle approach to CVD risk reduction, selected programs now offer intensive CR (ICR), during which participants may receive up to 72 structured exercise and/or educational counseling sessions over an 18-week duration. Reported outcomes from such programs, which generally embrace Pritikin or Ornish-based methodologies, include reductions in body weight and fat stores, blood lipids, hemoglobin A1c, and resting BP, and improvements in psychosocial variables, exercise capacity, and dietary habits.29-31 Related intensive lifestyle modification programs in symptomatic CHD patients have been shown to reduce subsequent hospitalization rates as compared with traditional or no CR, although only a trend toward lower mortality was observed.32
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ACCEPTED MANUSCRIPT Unfortunately, transportation problems, extended drive time, work or caregiver-related responsibilities, excessive insurance co-pays, and limited program accessibility represent
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common barriers to attending traditional center-based CR. In such cases, home-based
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programming involving structured exercise, self-monitoring documentation, telephone or periodic “in-person” electrocardiographic telemetry-monitored exercise sessions, and other
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technology-based education and communication strategies (e.g., telephonic coaching, text and
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video messaging) may be considered, with healthcare providers as an adjunct to or replacement for traditional group CR services.33,34 Such contemporary methodologies, when used in
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conjunction with home-based CR programs, appear to provide physiologic, clinical, and quality
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of life outcomes that are comparable to center-based programs in lower-risk CVD patients.35
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The Changing Face of Healthcare: Patient Centered Home-Based Interventions The Patient Centered Medical Home is an evolving community-based health program that places
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the patient at the center of care. Gabbay et al. are currently evaluating patients (n = ~10,000)
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with T2D who are participating in a multiprofessional healthcare team intervention in a variety of healthcare settings.36 The healthcare team includes physicians, nurses, nurse practitioners, clinical nurse specialists, nutritionists, physical therapists, occupational therapists, and social workers, representing an effective and efficient collaboration. The intervention, which is based on the chronic care model of Wagner and associates,37,38 relies heavily on health system leadership designed to support patient self-management, intervention decisions, and evaluation. It is predicated on adequate financial reimbursement for healthcare providers, including pay-forperformance. At 1 year, improvement was noted in patients’ adherence to prescribed medications, including aspirin, statins, ACEI and ARBs (Table 2). In addition, as compared to
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ACCEPTED MANUSCRIPT baseline, the percentages of patients undergoing annual eye and foot examinations, receiving pneumococcal vaccinations, and achieving smoking cessation were improved.36 This
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community-based model has the potential to greatly improve the delivery and effectiveness of
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healthcare.
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The Importance of National Leadership Partnering with Communities
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Contemporary smoking rates among adults and teenagers are now half of what they were in 1964. A recent Surgeon General’s report entitled “The Health Consequences of Smoking, 50
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years of Progress,”39 highlights the community-based partnerships that were key to successfully reducing cigarette smoking in the US and explains how the 1964 national declaration of the
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dangers of cigarette smoking was able to effectively empower states, cities, communities, and
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individuals to stop smoking. The Surgeon General's report further describes proven control strategies and programs that included political advocacy, as well as healthcare-related and
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community-based initiatives. The report also notes, however, that effective evidence-based
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tobacco control interventions, including promoting quitting, raising tobacco excise taxes to sufficiently high rates to deter young people from smoking, providing easy access to proven smoking cessation treatment in clinical settings, adopting smoke-free policies, and enacting comprehensive state-wide tobacco control programs, remain underused. Moreover, the report proposed additional strategies to eliminate tobacco smoking, in particular, reduction of the nicotine yield of tobacco products to non-addictive levels. It is the responsibility of CB HLIs to target smoking cessation as an integral part of their overall health promotion efforts.39
Conclusions
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ACCEPTED MANUSCRIPT Puska has emphasized that lifestyles “are enrooted in social and physical environments.”1 Since the 1970s, a variety of CB HLIs in Europe and the US have demonstrated the potential of
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communities to provide education, reinforcement, and support interventions that CVD patients
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and those with CVD risk factors require to achieve healthy lifestyle change. Some of these involve collaborations between community-based and national healthcare organizations, such as
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the partnership between YMCAs and athenahealth. Others have enlisted the participation of
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CHWs, who can provide effective outreach and other critically needed services, or FBOs, which have the ability to reach the underserved or uninsured across racially and ethnically diverse
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populations. Among CB HLIs, CR programs can greatly improve the physical and emotional health of cardiac patients and support them in their lifestyle changes, but these programs remain
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vastly underutilized. To remedy this, contemporary interventions are being developed to tailor
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CR to the needs of potential participants who may, for a variety of reasons, be unable to attend traditional center-based programs. Working together, healthcare teams have achieved positive
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results by delivering interventions to patients in a variety of healthcare settings, including in their
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homes. All these interventions, while spearheaded by and within communities, have been most effective when they have had state-wide and national support. Pioneering and ongoing CB HLIs have shown the potential of communities to help their members to achieve healthy lifestyle changes, likely reducing the enormous toll of CVD on individuals, society, and the economy.
References 1. Puska P: Community-based cardiovascular prevention programs: theory and practice. Arch Iran Med. 2013;16:2-3.
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ACCEPTED MANUSCRIPT 2. Yusuf S, Reddy S, Ôunpuu S, et al. Global burden of cardiovascular diseases. Part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization.
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Circulation. 2001;104:2746-2753.
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3. AHA Heart Disease and Stroke Statistics at-a -Glance. Available at: http://professional.heart.org/idc/groups/ahamah-
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public/@wcm/@sop/@smd/documents/downloadable/ucm_480086.pdf. Accessed 9-26-16.
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4. Centers for Disease Control and Prevention. Available at:
http://www.cdc.gov/chronicdisease/overview. Accessed 9-26-16.
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5. Pearson TA, Palaniappan LP, Artinian NT, et al. American Heart Association Guide for improving cardiovascular health at the community level, 2013 update. Circulation. 2013;
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127:1730-1753.
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6. Fortmann SP, Williams PT, Hulley SB, et al. Effect of health education on dietary behavior: the Stanford Three Community Study. Am J Clin Nutr. 1981;34:2030-2038.
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7. Farquhar JW, Fortmann SP, Flora JA, et al. Effects of communitywide education on
365.
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cardiovascular disease risk factors. The Stanford Five-City Project. JAMA. 1990;264:359-
8. Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factors during comprehensive five-year community programme to control cardiovascular diseases (North Karelia project). Br Med J. 1979;2:1173-1178. 9. Jousilahti P, Laatikainen T, Peltonen M, et al. Primary prevention and risk factor reduction in coronary heart disease mortality among working aged men and women in eastern Finland over 40 years: population based observational study. BMJ. 2016;352:i721.
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ACCEPTED MANUSCRIPT 10. YMCA and athenahealth partner on community health. Available at: www.ymca.net/newsreleases/ymca-and-athenahealth-partner-community-integrated-health. Accessed September
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26, 2016.
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11. Ackermann RT, Finch EA, Brizendine E, et al. Translating the Diabetes Prevention
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Program into the Community. The DEPLOY Pilot Study. Am J Prev Med. 2008;35:357-363.
12. YMCA of the USA Community Integrated Health Efforts Support U.S. Department of Health
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and Human Services in Historic Diabetes Prevention Program Certification by Medicare.
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Available at: http://www.ymca.net/news-releases/ymca-usa-community-integrated-healthefforts-support-us-department-health-and-human. Accessed November 5, 2016.
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13. Landers S, Levinson M. Mounting evidence of the effectiveness and versatility of community health workers. Am J Public Health. 2016;106:591-592.
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14. Kim K Choi JS, Choi E, et al. Effects of community-based health worker interventions to
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improve chronic disease management and care among vulnerable populations: a systematic review. Am J Public Health. 2016;106:e3-e28.
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15. Allen JK, Dennison-Himmelfarb CR, Szanton SL, et al. Community Outreach and Cardiovascular Health (COACH) trial: a randomized controlled trial of nurse practitioner/ community health worker cardiovascular disease risk reduction in urban community health centers. Circ Cardiovasc Qual Outcomes. 2011;4:595-602. 16. Krantz MJ, Coronel SM, Whitley EM, et al. Effectiveness of a community health worker cardiovascular risk reduction program in public health and health care settings. Am J Public Health. 2013;103:e19-e27.
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ACCEPTED MANUSCRIPT 17. DeHaven MJ, Hunter IB, Wilder L, et al. Health programs in faith-based organizations: are
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they effective? Am J Public Health. 2004;94:1030-1036.
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18. Wood DA, Kotseva K, Connolly S, et al. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary
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heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet. 2008;371:1999-2012.
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19. Connolly S, Holden A, Turner E, et al. MyAction: an innovative approach to the prevention
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of cardiovascular disease in the community. Br J Cardiol. 2011;18:171-176. Available at: https://bjcardio.co.uk/2011/08/myactionaninnovativeapproachtothepreventionofcardio
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vasculardisease. Accessed October 31, 2016.
20. Gibson I, Flaherty G , Cormican S, et al. Translating guidelines to practice: findings from a
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multidisciplinary preventive cardiology programme in the west of Ireland. Eur J Prev
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Cardiol. 2014;21:366-376.
21. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk
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reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-2473. 22. Suaya JA, Shepard DS, Normand ST, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2013; 127:1730-1753. 23. Sandesara PB, Lambert CT, Gordon NF, et al. Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.” J Am Coll Cardiol. 2015;65:389-395.
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ACCEPTED MANUSCRIPT 24. Newby LK, LaPointe NM, Chen AY, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113:203-212.
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25. Ho PM, Magid DJ, Shetterly SM, et al. Medication nonadherence is associated with a broad
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range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155:772-779.
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26. Arnold SV, Spertus JA, Masoudi FA, et al. Beyond medication prescription as performance
J Am Coll Cardiol. 2013;62:1791-1801.
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measures: optimal secondary prevention medication dosing after acute myocardial infarction.
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27. Chow CK, Jolly S, Rao-Melacini P, et al. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes.
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Circulation. 2010;121:750-758.
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28. Brinks J, Fowler A, Franklin BA, et al. Lifestyle modification in secondary prevention: beyond pharmacotherapy. Am J Lifestyle Med. May 30, 2016 doi:
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10.1177/1559827616651402.
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29. Franklin BA, Brinks J. Cardiac rehabilitation: underrecognized/underutilized. Curr Treat Options Cardiovasc Med. 2015;17:62. doi: 10.1007/s11936-015-0422-x. 30. Silberman A, Banthia R, Estay IS, et al. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am J Health Promot. 2010;24:260-266. 31. Aldana SG, Greenlaw R, Salberg A, et al. The effects of an intensive lifestyle modification program on carotid artery intima-media thickness: a randomized trial. Promot. Am J Health Promot. 2007;21:510-516.
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ACCEPTED MANUSCRIPT 32. Zeng W, Stason WB, Fournier S, et al. Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries. Am Heart J.
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2013;165:785-792.
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33. Sangster J, Furber S, Allman-Farinelli M, et al. Effectiveness of a pedometer-based telephone coaching program on weight and physical activity for people referred to a cardiac
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rehabilitation program: a randomized controlled trial. J Cardiopulm Rehabil Prev.
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2015;35:124-129.
34. Maddison R, Pfaeffli L, Whittaker R, et al. A mobile phone intervention increases physical
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activity in people with cardiovascular disease: Results from the HEART randomized controlled trial. Eur J Prev Cardiol. 2015;22:701-709.
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35. Dalal HM, Zawada A, Jolly K, et al. Home based versus centre based cardiac rehabilitation:
10.1136/bmj.b5631.
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Cochrane systematic review and meta-analysis. BMJ. 2010;340:b5631. doi:
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36. Gabbay RA, Bailit MH, Mauger DT, et al. Multipayer patient-centered medical home
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implementation guided by the chronic care model. Jt Comm J Qual Patient Saf. 2011; 37:265-273.
37. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Quarterly. 1996;74:511-544. 38. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effect Clin Pract. 1998;1:2-4. 39. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. National Center for Chronic Disease Prevention and Health Promotion (US) Office
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ACCEPTED MANUSCRIPT on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-
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years-of-progress/full-report.pdf. Accessed October 21, 2016.
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ACCEPTED MANUSCRIPT Table 1. Research Studies in Community-based Healthy Lifestyle Interventions Name and Date of Study Stanford ThreeCommunity Study, 1981 (Fortmann et al. 1981)6
Location
Population (n*)
Duration Primary Endpoint
Methods
Results
2 communit ies in rural northern California :2 treatment and 1 control
Random sample of men and women 35-59 years of age.
2 years active study; 1 year followup
Dietary education using mass media, selfreported results on questionnaires
Stanford Five-City Project (Farquhar et al. 1990)7
2 treatment and 2 control cities in rural northern California
Cross-sectional 14 years population samples, ages 2574. (n = 1255 in treatment cities)
Changes in knowledge of CV risk factors
23%-34% reductions in dietary cholesterol; 25%-30% reductions in saturated fat. These reductions were significant vs controls. Changes were maintained or further improved in Year 3 Significant reductions with treatment in BP, plasma cholesterol, resting pulse rate, and smoking rate, as well as in CHD risk and total mortality risk
North Karelia Project (Puska et al. 1979)8
North Karelia county, Finland
Representative population samples; men and women ages 26-64 with and without CVD (n = >10,000)
Reductions in smoking, serum cholesterol, and BP
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Cholesterol, body weight
5 years
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General education plus separate risk factor educational campaigns. Program included social learning theory, social marketing, community organization principles; results selfreported in surveys, at baseline and 3 years later Intensive, comprehensive community program
Mean net reduction of CHD of 19% in men and 12% in women.
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DEPLOY Ackermann et al. 2008)11
2 YMCAs in greater Indianapo lis
92 men and women with risk factors for type 2 diabetes
EUROACTI ON (Wood et al. 2008)18
6 pairs of hospitals and 6 pairs of general practices in 8 European countries (interventi on and usual care)
COACH
Communi
40 years
Change in principal CHD risk factors, change in CHD mortality
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Change in weight , blood pressure, Hemoglobin A1c, total cholesterol and HDLcholesterol
6-month lifestyle intervention aimed at behavior change, including diet, weight loss, and physical activity. Changes were sustained at 1 year follow-up
Patients with CVD (n = 3088) or at high risk of developing CVD (n = 2317)
1-year assessme nt; program ran for 3 years 5 months
Weekly workshops and exercise class, prescription of cardioprotective drugs; regular monitoring of risk factors and adherence to treatment
Patients with
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Familybased lifestyle change; BP, lipids, blood glucose to target concentratio ns; smoking cessation; prescription of cardioprotect ive drugs Changes in
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6 months with followup at 1 year
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Analysis of the role of primary prevention and risk factor change in CHD mortality trends over 40 years in the Puska 8 study population. Measure the contribution to CHD mortality trends from three major risk factors (smoking, blood pressure,choleste rol).
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Men and women aged 30-59 years who participated in national FINRISK studies between 1972 and 2012 (n = 34,525)
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Eastern Finland
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Eastern Finland study (Jousilahti et al. 2016)9
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Intensive
CHD mortality decreased by 82% and 84% among men and women, respectivel y, as a result of reductions in three main CV risk factors: smoking, BP, and serum cholesterol Average weight loss of 6% (Interventio n) vs 2% (Control) p <0.001. Greater change on Total Cholesterol -22 vs +6 mg.dL, p = 0.001 Reductions in risk of CVD, including weight loss, mainly through lifestyle changes
Significant
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London, UK
MyAction Galway (Gibson et al. 2014)20
Galway, Ireland
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Patients with coronary disease, high-risk adults and partners (n = 412)
Patients with coronary disease, high-risk adults and partners (n = 556 completing program, 342 at 1-year follow-up)
pharmacologic and lifestyle management
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MyAction UK (Connolly et al. 2011)19
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Urban, rural, and frontier regions of Colorado.
knowledge of CV risk factors
Changes in CVD risk factors and FRS
16 weeks for hospital patients; open ended for general practice patients
16 weeks with 1 year followup
improveme nt in CVD risk profiles; greater understandi ng of CVD
Significant improveme nts in diet, weight, blood pressure, lipids, and FRS Lifestyle Group workshop, Reductions change; motivational in risk of management interviews, CVD of BP, lipids supervised through and blood exercise family glucose, (hospitalized lifestyle prescription patients), changes, of personal record mainly diet cardioprotect card for lifestyle and ive drugs and risk factor physical targets activity Lifestyle Individualized Improveme change; and group nts in management education, lifestyle, of BP, lipids interventions, psychosoci and blood medical al and glucose, management medical prescription risk factors of cardioprotect ive medications
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Colorado Health Hearts Solution (CHHS) (Krantz et al. 2013)16
CVD, type 2 months diabetes, hypercholesterol emia or hypertension or levels of LDL-C, BP, or HbA1c in excess of goals in national guidelines (n = 525) Medically ≥3 underserved months populations (n = 698; 15% at high risk)
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ty health centers in low income areas
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Trial (Allen et al. 2011)15
Risk factor screening and motivational interviewing to facilitate behavior change
BP, blood pressure; CHD, coronary heart disease; COACH, Community Outreach and Cardiovascular Health; CV, cardiovascular; CVD, cardiovascular disease; DPP, diabetes prevention program; FRS, Framingham Risk Score. *n where available.
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ACCEPTED MANUSCRIPT Table 2. 1-Year Results: Patient-Centered Medical Home36
Baseline Mean Percentage
Value at 1 year
Eye exam
30.4
41.2*
Foot exam
50.6
Microalbumin
62.7
Pneumonia vaccination
25.5
Smoking cessation
57.0
Evidence-based treatment
Baseline Mean
Value at 1 year
Aspirin
50.8
64.2*
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Evidence-based screening
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69.0*
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69.1*
Statin
57.5*
42.3
55.6*
50.5
70.0*
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Self-management goal
71.0*
36.1
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ACE/ARB
42.4*
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ACE, angiotesin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; *Indicates a significant difference at Year 1 compared to baseline (p <0.05).
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ACCEPTED MANUSCRIPT Figure 1.
Interventions of Multidisciplinary Healthcare Team in MyAction Program (19)
Copyright of Medinews (Cardiology) Limited, reproduced with permission' 12/29/16.
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At the initial assessment, patients and their partners were seen together and were then individually assessed by members of the multidisciplinary team for smoking habit; diet; weight, height, body mass index, and waist circumference; physical activity levels; functional capacity; psychosocial measures; blood pressure; fasting lipids and glucose; and use of cardioprotective medications. The 16-week progam included individual follow-up, a weekly educational workshop and supervised exercise sessions, in which all members of the multidisciplinary team took part. A weekly meeting between the multidisciplinary team and cardiologist reviewed lifestyle, risk factors and therapeutic goals. The nurse and cardiologist followed established protocols for risk factor management.
Figure 1 Copyright
of Medinews (Cardiology) Limited, reproduced with permission' 12/29/16. 30
S0033-0620(17)30001-4 doi: 10.1016/j.pcad.2017.01.002 YPCAD 782
To appear in:
Progress in Cardiovascular Diseases
Received date: Accepted date:
2 January 2017 2 January 2017
Please cite this article as: Berra Kathy, Franklin Barry, Jennings Catriona, CommunityBased Healthy Lifestyle Interventions, Progress in Cardiovascular Diseases (2017), doi: 10.1016/j.pcad.2017.01.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Community-Based Healthy Lifestyle Interventions
Kathy Berra, MSN, NP, FAHA, FPCNA, FAAN, Co-Director The LifeCare Company;
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Nurse Practitioner, Cardiovascular Medicine and Coronary Interventions, Stanford Prevention
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Research Center, Stanford University School of Medicine (ret), USA
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Barry Franklin, PhD, FACSM, MACVPR, FAHA, Director, Preventive Cardiology & Cardiac Rehabilitation, William Beaumont Hospital Royal Oak, Michigan; Professor, Internal Medicine,
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Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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Catriona Jennings, PhD, FESC, Programme Leader and Senior Teaching Fellow for the MSc, PG Diploma and PG Certificate in Preventive Cardiology, Cardiovascular Specialist Research Nurse,
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Faculty of Medicine, NHLI Imperial College London, United Kingdom
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Corresponding author:
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Conflicts of Interest:None
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Kathy Berra, MSN, NP, FAHA, FPCNA, FAAN 1825 White Oak Drive Menlo Park, CA 94025 Phone: 650 722 2605 Fax: 1877 576 4182 [email protected]
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Abbreviations:
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1. YMCA - Young Men’s Christian Association 2. DPP – Diabetes Prevention Program 3. ACEI-Angiotensin Converting Enzyme Inhibitor 4. ARB- Angiotensin Receptor Blocker 5. BP – Blood Pressure 6. CB HLIs - Community-based healthy lifestyle interventions 7. CHD-Coronary Heart Disease 8. CV- Cardiovascular 9. CVD - Cardiovascular Disease 10. CR - Cardiac Rehabilitation 11. CHD - Coronary Heart Disease 12. CDC - Centers for Disease Control 13. DEPLOY - Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA 14. CHWs - Community Health Workers 15. COACH - Community Outreach and Cardiovascular Health 16. FBO - Faith-based organizations 17. HTN= Hypertension 18. ICR - Intensive Cardiac Rehabilitation 19. PA –Physical Activity 20. SCORE - Systematic Cardiovascular Risk Estimation 21. T2D –Type 2 Diabetes
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Abstract
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In an environment in which most people have lifestyles that increase risk for initial or recurrent cardiovascular disease ( CVD) events, community-based healthy lifestyle initiatives are highly
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effective in providing programs, education and support to reduce associated CVD risk factors and improve outcomes. Pioneering programs, such as the Stanford Three Community and Five
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Cities studies, and the North Karelia project in Finland, served as prototypes for current
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initiatives. These include partnerships with national organizations (e.g., YMCA DPP) and faithbased programs. Training may be provided by healthcare professionals and/or community
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healthcare workers; initiatives include exercise-based and weight-reduction programs, smoking
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cessation interventions, dietary counseling and education, and medication adherence. Contemporary technologies and home-based programs provide alternatives to those who might not otherwise have access to center-based programs. Community-based initiatives, particularly those with state or national support, have the potential to enhance the delivery and effectiveness of CVD prevention at low cost. Word count: 146 of 150 permitted
Key words: Cardiovascular prevention Cardiac rehabilitation
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ACCEPTED MANUSCRIPT Cardiovascular risk factor Community healthcare
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Community-Based Healthy Lifestyle Interventions
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Lifestyle
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This review summarizes the important role of community-based healthy lifestyle interventions (CB HLIs) in the primary and secondary prevention of cardiovascular (CV) disease (CVD) and
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related efforts to recruit and enhance community involvement in these risk-reduction programs. We provide an overview of CB HLIs from research initiatives in the 1970s to ongoing trials and
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noteworthy clinical investigations of the 21st century. We also discuss the impact of European
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models, highlighting the pioneering studies of Drs. Puska, Fortmann, and Farquhar. In addition, we review the methodology, effectiveness, and efficacy of traditional and non-traditional cardiac
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interventions.
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rehabilitation (CR) programs, with specific reference to community and home-based
Rationale for CB HLIs
Following World War II, increasing evidence began to accumulate regarding the link between lifestyle risk factors and the prevalence of atherosclerotic CVD and stroke. Epidemiologic research supported the hypothesis that certain risk factors were likely to be causal, but randomized controlled trials were needed to further substantiate this relation.1 Established or conventional lifestyle risk factors include cigarette smoking, low physical activity (PA) , overweight and obesity, dyslipidemia, high blood pressure (BP), elevated blood glucose (including type 2 diabetes/T2D), and poor dietary habits, such as excess sodium, saturated fat, 4
ACCEPTED MANUSCRIPT trans fat, calories, and sugar intake, as well as inadequate consumption of fruits, vegetables, and whole grains. High levels of stress and other psychosocial modulators (e.g., depression, anxiety,
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social isolation) have also been implicated, either directly or indirectly, in the development of
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CVD.2 Interestingly, between 2003 and 2013, although CVD mortality decreased ~38%, the burden of some coronary heart disease (CHD) risk factors (e.g., obesity, T2D, physical
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inactivity) remained high.3
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The American Heart Association 2016 Heart Disease, Stroke, and Research Statistics reported that CVD remains the leading global cause of death, accounting for >17.3 million
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deaths per year, and this is expected to increase to almost 24 million by 2030. In 2013, CVD deaths accounted for 31% of all global deaths, with the highest burden found in low- to middle-
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income countries. The worldwide prevalence of stroke approximated 33 million, making it the
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second leading cause of death, immediately following CHD. Thus, the direct and indirect cost for healthcare expenditures and lost productivity resulting from CVD was estimated at $317 billion.3
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The Centers for Disease Control (CDC), in a recent review, noted that in 2010 chronic
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diseases were responsible for 7 of the top 10 causes of death, and that CVD and cancer together accounted for 48% of all deaths.4 The report listed obesity and T2D among the leading causes of disability and excess healthcare costs. Moreover, in 2011, more than half of all American adults were not exercising regularly, and 76% did not meet minimum recommendations for PA. In addition, 1 in every 5 adults (> 42 million) reported smoking cigarettes every day. More than 3200 Americans under 18 years of age smoked their first cigarette in 2012, and many of these are expected to become regular smokers. In 2010, the CDC estimated that the total costs for CVD and diagnosed T2D were $315.4 billion and $245 billion, respectively. These estimates include both direct medical costs and decreased productivity.4
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ACCEPTED MANUSCRIPT These enormous costs to society, individuals, and communities substantiate the need for CB HLIs and expanded research initiatives. The challenge is to effectively support healthy lifestyle
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interventions at the national, state, and community level. With medical advances and increased
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access to both primary and specialty care in the United States, communities hold great promise in supporting efforts to reduce CVD risk factors by implementing healthy lifestyle intervention
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programs.4,5
Community-based Healthy Lifestyle Research – Early Lessons Learned
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In 1981, Fortmann et al. reported the results of a CV health education program in 2 communities in Northern California.6 The goal was to determine whether a health education program could
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favorably modify conventional CVD risk factors. The Stanford Three Community Study used a
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comprehensive, multifactorial approach to risk factor reduction. The intervention and control cities were in a semi-rural, primarily agricultural area of northern California. A random
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sampling of men and women between 35 and 59 years of age were invited to participate in the
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baseline survey during the fall of 1972. The 2-year health education intervention was followed by a maintenance year, during which risk reduction efforts were continued. Subsequent annual surveys were repeated through 1975.6 The intervention was based on mass media health education. Although the targeted communities were separated from the control community by a range of low hills, the former shared a television station that was not accessible to the control community. Educational information was provided through television, radio, billboards, newspapers, pamphlets, cookbooks, and direct mail. The campaign was designed to be bilingual, given the ethnicity and culture of these communities. Both men and women in the intervention communities reported
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ACCEPTED MANUSCRIPT (self-report) reductions in dietary cholesterol (23% to 34%) and dietary saturated fat (25% to 30%) that were greater than those reported in the control community. Similar trends were noted
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for changes in plasma cholesterol. In the maintenance year, the beneficial changes observed in
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the second year were maintained or slightly improved. The researchers concluded that 3-year multifaceted health education delivered by mass media campaigns improved dietary practices
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and reduced plasma cholesterol. Although body weight increased in the control community, the
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researchers partially attributed this to the aging of the entire cohort during the intervention.6 Following this seminal study, Stanford researchers tested whether changes in knowledge
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about CVD risk factors might correlate with a reduction in disease prevalence. The Stanford Five-City Project, a comprehensive, low-cost project based on social learning theory derived
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from the initial Three Community Study, used social marketing methods equating to
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approximately 26 hours of exposure to risk reduction education. Following 30 to 64 months of education, improvements in plasma cholesterol levels, BP, resting pulse rate, and smoking
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cessation rates were observed in the treatment cohort. These changes resulted in decreases in
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composite total mortality risk scores (15%) and CHD risk scores (16%). The Five-City Project was 5 years in duration. Investigators concluded that low-cost CB HLIs can reach the public in various cost-effective and efficient ways and may decrease the morbidity and mortality associated with CVD.7 The North Karelia project, another seminal CB HLI, was launched in 1972, simultaneous to the Stanford Three City and Five City studies. It was undertaken to address the causes of and treatments for the extremely high rates of CVD morbidity and mortality in Finland. The emphasis was on smoking cessation, reductions in serum cholesterol, and improvements in BP. The project targeted middle-aged men, who, at that time, suffered the highest rates of CVD
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ACCEPTED MANUSCRIPT morbidity and mortality. As with the Stanford studies, investigators tested the feasibility and effectiveness of a community-based approach to risk reduction. It was hypothesized that the
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North Karelia project, if successful, could serve as an effective prototype for future CB HLIs.8
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This project was integrated into the healthcare system and social service programs. The interventions focused on “practical activities” to reduce risk factors, based on public education
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and supported by radio, posters, meetings, and media campaigns that were conducted in schools
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and places of work. Because Finland has national healthcare services, the education was incorporated into those services so as to reach individuals already receiving treatment for chronic
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medical conditions and CVD risk factors. Intervention staff included teachers, volunteer workers, and community leaders, influential members of the community who were able to
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integrate their efforts into established services.8
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Puska and colleagues reported an overall participation rate of 90% in the study population, approximating 10,000 subjects, aged 35 to 64 years. Decreases in risk factors were
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observed in both men and women, with greater relative reductions in men. Multiple regression
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analysis showed that overall mean net reductions in estimated CHD risk were 17% and 12% among men and women, respectively. The investigators concluded that this program was highly effective in reducing conventional CHD risk factors, and that additional study of CB HLIs was warranted.8 Based on the success of the North Karelia project, the National Institute for Health and Welfare in Finland, in association with the University of Eastern Finland Institute of Public Health and Clinical Nutrition, continued the population-based risk factor survey every 5 years from 1972 to 2012. The results of this CB HLI showed that during the 40-year study period, improvements in the three major risk factors assessed (cigarette smoking, serum cholesterol, and
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ACCEPTED MANUSCRIPT BP) were associated with reduced rates of CHD among men and women, 82% and 84%, respectively. The observed decrease in CVD mortality was primarily attributed to reductions in
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the three targeted risk factors.9
Community Organizations and Community-Based Healthy Lifestyle Interventions
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A well-known community-based nonprofit organization that has contributed to improved health
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in the United States is the Young Men's Christian Association (YMCA). There are approximately 2400 YMCAs across the US, serving ~22 million men, women, and children,
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regardless of age, income, ethnicity or socioeconomic background. Their focus is on healthy living and social responsibility, with particular emphasis on improved health and well-being
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through varied wellness initiatives over the past 40 years.10
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The YMCA and athenahealth recently partnered on a novel intervention that was based on the YMCA’s proven success with a diabetes prevention program (DPP), that is, the Diabetes
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Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) pilot.
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This DPP targeted adults at risk of developing T2D. DEPLOY demonstrated that well trained YMCA wellness instructors could implement a group-based educational DPP. At 6 months, greater weight loss and lower total cholesterol were found in intervention participants as compared with control subjects. This difference was maintained at 1 year.11
Working with athenahealth, in a coordinated effort with the Center for Medicare and Medicaid Innovation, the YMCA delivered the DPP to nearly 8000 participants over 3 years. Numerous other health organizations also assisted with the intervention. The YMCA worked closely with the American Diabetes Association in awareness building and the formation of
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ACCEPTED MANUSCRIPT policy changes that enabled prevention programs to be incorporated into health-care systems and community-based organizations. The CDC helped fund this program, and the American Medical
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Association partnered with the YMCA to ensure that physicians and other healthcare providers
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understood the goals of the program, enabling them to support it through referrals. In February 2016, the YMCA DPP announced that they had served over 42,000 participants at >1400 sites in
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45 states across the country, resulting in an average weight loss of 4.6% at the end of weekly
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sessions, and 5.5% at the end of the year.12
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The new partnership with athenahealth will allow the YMCA to increase the implementation of its DPP program in YMCAs across the country. Jonathan Bush, CEO of
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athenahealth, stated that "Care is moving out of the hospital and into more fiscal, convenient, and
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cost-effective venues." According to Dr. Matt Longjohn, national health officer of Y-USA, “The YMCA's DPP shows that community-integrated health, delivered outside of traditional clinical
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studies, is highly effective in delivering strong health outcomes.” He added that "the Y's mission
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to address gaps in care in order to improve outcomes while lowering costs is shared by athenahealth and is essential to un-break health care."10 The association between the YMCA and athenahealth demonstrates the ways in which collaborations between community-based and national health organizations can enhance synergies and improve the effectiveness of any given intervention.
Community health workers and CB HLIs
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ACCEPTED MANUSCRIPT The role of community health workers (CHWs) as integral contributors to the healthcare team is now increasingly accepted. CHWs, also called health navigators and promoters, contribute in
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numerous ways to CB HLIs. As active members of the community, CHWs provide trusted
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linkages with local community services. These individuals are generally bilingual, viewed as culturally sensitive to public health initiatives, and can assist with data collection and outcome
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assessments. They also serve as outreach workers to members of their community and can
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support case management.13,14 CHWs have effectively supported both cancer and CVD risk reduction programs in a cost-effective manner.14
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Community Outreach and Cardiovascular Health (COACH), a randomized controlled trial that used nurse practitioners as well as CHWs to target CVD risk reduction in urban
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community health centers, demonstrated significant positive outcomes.15 COACH enrolled 525
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patients with CVD, T2D, hypercholesterolemia, hypertension (HTN), or combinations thereof, from low-income minority populations. More than 70% of the study participants were women
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and 79% were black. The goals were to provide intensive pharmacologic and lifestyle
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management over a 12-month period, plus counseling aimed at overcoming common adherence barriers to treatment. When compared with controls, treatment subjects demonstrated significantly greater reductions in low-density lipoprotein cholesterol, triglycerides, systolic and diastolic BP, and hemoglobin A1c, as well as improved perceptions of the quality of their chronic disease care. This innovative model of care has great promise, especially for community residents who may be less able to afford or access relevant healthcare services.15 Krantz and colleagues evaluated whether an ongoing CVD risk reduction program, Colorado Heart Health Solutions, which was led by CHWs and integrated into both public health and healthcare settings, measurably reduced the population risk of CHD.16 As part of Colorado
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The program was expanded to include: (1) a decision-support algorithm to provide guideline-
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based and tailored health messages; (2) assessment of participant readiness to change; (3) promotion of health behavior change utilizing motivational interviewing; (4) long-term follow-
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up for high-risk persons; (5) improved access to and navigation of medical care and community
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resources; and, (6) integration of healthcare provider educational detailing. During 2011 and 2012, 4743 participants at risk for CHD received medical or lifestyle referrals at the time of
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screening, and 698 (15%) were retested 3 or more months following baseline screening. Significant improvements in diet, weight, BP, lipids, and Framingham Risk Score were noted at
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follow-up. Phone contact with a CHW was associated with greater improvement in the
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Framingham Risk Score, further demonstrating that CHWs in public health and healthcare
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settings can improve CVD risk factors through screening and behavior change.16
Faith-based organizations (FBO) have a long history of partnering with healthcare
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providers and other social services in the community to provide health screenings, health education, and social services, such as mental health counseling and geriatric care. DeHaven et al. reviewed the relevant health literature over a decade (1990 – 2000), with specific reference to FBOs and health outcomes.17 The latter included improvements in overall health status, increased fruit and vegetable consumption, weight loss and blood pressure reduction. The authors noted that most programs focused on general health maintenance, primary prevention, cardiovascular health, and cancer. Programs were described as faith placed (health professionals used the church to test an intervention), faith based (the program is part of the church health ministry), or community programs. Of those studies that met search criteria, reported effects
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ACCEPTED MANUSCRIPT included significant reductions in cholesterol and BP, body weight, and disease symptoms, and increases in the use of mammography and breast self-examination. Over half of the programs
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compared with faith-based or collaborative interventions.17
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(52.8%) reported outcome measures, with faith-placed programs being more likely to report
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The authors suggested that for the 43 million uninsured in the United States, faith/churchbased community health interventions provide a viable approach to potentially reduce morbidity
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and mortality from chronic diseases. They recommend increased collaboration between health
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professionals and FBOs focused on the evaluation of health-related activities and dissemination of health findings, placing a greater emphasis on the effectiveness of the interventions, as
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opposed to their efficacy, and paying greater attention to building relationships with racially and ethnically diverse communities.17 Church-based health-care activities are increasingly important
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in supporting underserved and aging populations in the U.S.
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ACCEPTED MANUSCRIPT Translating Research into Community-Based Practice EUROACTION was a pioneering research trial that evaluated a hospital, clinic, and
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community-based nurse-coordinated multidisciplinary, family-based CVD prevention program.
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EUROACTION included patients hospitalized with CHD and their partners and high-risk patients and their partners from general practices in 8 countries across Europe, including the
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United Kingdom. At the end of 1 year, EUROACTION achieved clinically meaningful
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multifactorial risk reduction across most variables for those assigned to the intervention group. Significant improvements in diet and physical activity were noted in both patients and their
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partners. These lifestyle changes were believed to confer the reductions found in CVD risk.18 MyAction for Our Hearts was a United Kingdom initiative, developed for the National
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Health Service and based on the EUROACTION model. It addressed multifactorial risk
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reduction in patients with CHD and high-risk adults in a community setting. Spouses, partners, and family members were also invited to participate in the intervention, in order to create an
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environment where social support may favorably contribute to the outcomes achieved. The
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MyAction interventions were based on behavior change strategy and individual goal setting and planning (Fig. 1).19 The intervention resulted in significant adherence to the Mediterranean diet, and heightened levels of physical activity as well as increases in measured functional capacity. Increased prescribed medications for CVD risk reduction and improved quality of life were reported in the intervention group compared with the controls.19 MyAction was also evaluated at the Croí Institute in Galway, Ireland.20 This communitybased primary prevention initiative included a 16-week intensive risk-reduction program with follow-up at 1 year. The study included men and women >40 years of age at increased risk of CVD (assessed by Systematic Cardiovascular Risk Estimation [SCORE] evaluation of ≥5%) and
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ACCEPTED MANUSCRIPT patients with newly diagnosed T2D with 2 additional risk factors (e.g., dyslipidemia, HTN, or smoking). Adherence to the program was high, with 87.2% of participants and 84.6% of partners
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completing the intervention. At 1 year, data were obtained from >90% of patients and partners.
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As with the London-based program, the Croí program reported improvements in lifestyle, measures of psychosocial health, and CVD risk factors at 16 weeks that persisted at 1 year.20
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In summary, CB HLIs, directed by healthcare professionals working with CHWs, have
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great potential to improve both health outcomes and quality of life in populations with and at high risk for CVD. The CB HLIs discussed, including the early studies, are further described in
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Table 1.
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The Role of Cardiac Rehabilitation Programs in the Community
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Exercise-based CR programs are an integral component of community-based secondary prevention interventions for CVD patients and their families. Staff include skilled medical and
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paramedical professionals trained in cardiology, nursing, CVD risk reduction, and exercise
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science, using guideline-driven therapies.21 The impact on families and communities for those who participate in CR programs is profound. Unfortunately, these outpatient interventions remain woefully underutilized,22 and, to become optimally effective, should be “rebranded and reinvigorated.”23 To this end, Sandesara et al. suggested expanding the responsibilities of CR professionals to include home- and community-based programs to manage multiple disease states, while simultaneously addressing common barriers to participation, especially in younger and older patients. In addition, the authors strongly urge CR programs to become centers of innovation by exploiting the power of mobile technology, which may be particularly helpful in home-based interventions.23
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(ACEI)/angiotensin receptor blockers (ARB), and lipid-lowering agents, that are effective in
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favorably modifying major CHD risk factors and reducing mortality in patients with CVD. However, because nonadherence to cardioprotective medications is common in clinical practice24
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and associated with a broad range of adverse outcomes,25 optimization of medication dosing,26
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and addressing prescription nonadherence should also be a high priority in secondary prevention/CR interventions.23 Aggressive lifestyle modification can be helpful in this regard,
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providing independent and additive benefits to drug-mediated reductions in CVD mortality, and a substantially lower risk of recurrent CVD events.27,28 Accordingly, community-based CR staff
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should routinely counsel their CHD patients to engage in structured exercise and increased
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lifestyle PA at moderate-to-vigorous intensities (>3 metabolic equivalents), consume a hearthealthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial
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stressors (e.g., depression, anxiety, social isolation) that may elevate CVD risk.29
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For CVD patients seeking a more aggressive lifestyle approach to CVD risk reduction, selected programs now offer intensive CR (ICR), during which participants may receive up to 72 structured exercise and/or educational counseling sessions over an 18-week duration. Reported outcomes from such programs, which generally embrace Pritikin or Ornish-based methodologies, include reductions in body weight and fat stores, blood lipids, hemoglobin A1c, and resting BP, and improvements in psychosocial variables, exercise capacity, and dietary habits.29-31 Related intensive lifestyle modification programs in symptomatic CHD patients have been shown to reduce subsequent hospitalization rates as compared with traditional or no CR, although only a trend toward lower mortality was observed.32
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programming involving structured exercise, self-monitoring documentation, telephone or periodic “in-person” electrocardiographic telemetry-monitored exercise sessions, and other
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technology-based education and communication strategies (e.g., telephonic coaching, text and
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video messaging) may be considered, with healthcare providers as an adjunct to or replacement for traditional group CR services.33,34 Such contemporary methodologies, when used in
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conjunction with home-based CR programs, appear to provide physiologic, clinical, and quality
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of life outcomes that are comparable to center-based programs in lower-risk CVD patients.35
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The Changing Face of Healthcare: Patient Centered Home-Based Interventions The Patient Centered Medical Home is an evolving community-based health program that places
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the patient at the center of care. Gabbay et al. are currently evaluating patients (n = ~10,000)
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with T2D who are participating in a multiprofessional healthcare team intervention in a variety of healthcare settings.36 The healthcare team includes physicians, nurses, nurse practitioners, clinical nurse specialists, nutritionists, physical therapists, occupational therapists, and social workers, representing an effective and efficient collaboration. The intervention, which is based on the chronic care model of Wagner and associates,37,38 relies heavily on health system leadership designed to support patient self-management, intervention decisions, and evaluation. It is predicated on adequate financial reimbursement for healthcare providers, including pay-forperformance. At 1 year, improvement was noted in patients’ adherence to prescribed medications, including aspirin, statins, ACEI and ARBs (Table 2). In addition, as compared to
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ACCEPTED MANUSCRIPT baseline, the percentages of patients undergoing annual eye and foot examinations, receiving pneumococcal vaccinations, and achieving smoking cessation were improved.36 This
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community-based model has the potential to greatly improve the delivery and effectiveness of
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healthcare.
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The Importance of National Leadership Partnering with Communities
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Contemporary smoking rates among adults and teenagers are now half of what they were in 1964. A recent Surgeon General’s report entitled “The Health Consequences of Smoking, 50
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years of Progress,”39 highlights the community-based partnerships that were key to successfully reducing cigarette smoking in the US and explains how the 1964 national declaration of the
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dangers of cigarette smoking was able to effectively empower states, cities, communities, and
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individuals to stop smoking. The Surgeon General's report further describes proven control strategies and programs that included political advocacy, as well as healthcare-related and
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community-based initiatives. The report also notes, however, that effective evidence-based
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tobacco control interventions, including promoting quitting, raising tobacco excise taxes to sufficiently high rates to deter young people from smoking, providing easy access to proven smoking cessation treatment in clinical settings, adopting smoke-free policies, and enacting comprehensive state-wide tobacco control programs, remain underused. Moreover, the report proposed additional strategies to eliminate tobacco smoking, in particular, reduction of the nicotine yield of tobacco products to non-addictive levels. It is the responsibility of CB HLIs to target smoking cessation as an integral part of their overall health promotion efforts.39
Conclusions
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ACCEPTED MANUSCRIPT Puska has emphasized that lifestyles “are enrooted in social and physical environments.”1 Since the 1970s, a variety of CB HLIs in Europe and the US have demonstrated the potential of
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communities to provide education, reinforcement, and support interventions that CVD patients
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and those with CVD risk factors require to achieve healthy lifestyle change. Some of these involve collaborations between community-based and national healthcare organizations, such as
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the partnership between YMCAs and athenahealth. Others have enlisted the participation of
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CHWs, who can provide effective outreach and other critically needed services, or FBOs, which have the ability to reach the underserved or uninsured across racially and ethnically diverse
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populations. Among CB HLIs, CR programs can greatly improve the physical and emotional health of cardiac patients and support them in their lifestyle changes, but these programs remain
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vastly underutilized. To remedy this, contemporary interventions are being developed to tailor
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CR to the needs of potential participants who may, for a variety of reasons, be unable to attend traditional center-based programs. Working together, healthcare teams have achieved positive
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results by delivering interventions to patients in a variety of healthcare settings, including in their
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homes. All these interventions, while spearheaded by and within communities, have been most effective when they have had state-wide and national support. Pioneering and ongoing CB HLIs have shown the potential of communities to help their members to achieve healthy lifestyle changes, likely reducing the enormous toll of CVD on individuals, society, and the economy.
References 1. Puska P: Community-based cardiovascular prevention programs: theory and practice. Arch Iran Med. 2013;16:2-3.
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ACCEPTED MANUSCRIPT 2. Yusuf S, Reddy S, Ôunpuu S, et al. Global burden of cardiovascular diseases. Part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization.
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Circulation. 2001;104:2746-2753.
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3. AHA Heart Disease and Stroke Statistics at-a -Glance. Available at: http://professional.heart.org/idc/groups/ahamah-
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public/@wcm/@sop/@smd/documents/downloadable/ucm_480086.pdf. Accessed 9-26-16.
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4. Centers for Disease Control and Prevention. Available at:
http://www.cdc.gov/chronicdisease/overview. Accessed 9-26-16.
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5. Pearson TA, Palaniappan LP, Artinian NT, et al. American Heart Association Guide for improving cardiovascular health at the community level, 2013 update. Circulation. 2013;
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127:1730-1753.
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6. Fortmann SP, Williams PT, Hulley SB, et al. Effect of health education on dietary behavior: the Stanford Three Community Study. Am J Clin Nutr. 1981;34:2030-2038.
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7. Farquhar JW, Fortmann SP, Flora JA, et al. Effects of communitywide education on
365.
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cardiovascular disease risk factors. The Stanford Five-City Project. JAMA. 1990;264:359-
8. Puska P, Tuomilehto J, Salonen J, et al. Changes in coronary risk factors during comprehensive five-year community programme to control cardiovascular diseases (North Karelia project). Br Med J. 1979;2:1173-1178. 9. Jousilahti P, Laatikainen T, Peltonen M, et al. Primary prevention and risk factor reduction in coronary heart disease mortality among working aged men and women in eastern Finland over 40 years: population based observational study. BMJ. 2016;352:i721.
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ACCEPTED MANUSCRIPT 10. YMCA and athenahealth partner on community health. Available at: www.ymca.net/newsreleases/ymca-and-athenahealth-partner-community-integrated-health. Accessed September
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26, 2016.
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11. Ackermann RT, Finch EA, Brizendine E, et al. Translating the Diabetes Prevention
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Program into the Community. The DEPLOY Pilot Study. Am J Prev Med. 2008;35:357-363.
12. YMCA of the USA Community Integrated Health Efforts Support U.S. Department of Health
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and Human Services in Historic Diabetes Prevention Program Certification by Medicare.
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Available at: http://www.ymca.net/news-releases/ymca-usa-community-integrated-healthefforts-support-us-department-health-and-human. Accessed November 5, 2016.
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13. Landers S, Levinson M. Mounting evidence of the effectiveness and versatility of community health workers. Am J Public Health. 2016;106:591-592.
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14. Kim K Choi JS, Choi E, et al. Effects of community-based health worker interventions to
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improve chronic disease management and care among vulnerable populations: a systematic review. Am J Public Health. 2016;106:e3-e28.
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15. Allen JK, Dennison-Himmelfarb CR, Szanton SL, et al. Community Outreach and Cardiovascular Health (COACH) trial: a randomized controlled trial of nurse practitioner/ community health worker cardiovascular disease risk reduction in urban community health centers. Circ Cardiovasc Qual Outcomes. 2011;4:595-602. 16. Krantz MJ, Coronel SM, Whitley EM, et al. Effectiveness of a community health worker cardiovascular risk reduction program in public health and health care settings. Am J Public Health. 2013;103:e19-e27.
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ACCEPTED MANUSCRIPT 17. DeHaven MJ, Hunter IB, Wilder L, et al. Health programs in faith-based organizations: are
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they effective? Am J Public Health. 2004;94:1030-1036.
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18. Wood DA, Kotseva K, Connolly S, et al. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary
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heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet. 2008;371:1999-2012.
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19. Connolly S, Holden A, Turner E, et al. MyAction: an innovative approach to the prevention
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of cardiovascular disease in the community. Br J Cardiol. 2011;18:171-176. Available at: https://bjcardio.co.uk/2011/08/myactionaninnovativeapproachtothepreventionofcardio
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vasculardisease. Accessed October 31, 2016.
20. Gibson I, Flaherty G , Cormican S, et al. Translating guidelines to practice: findings from a
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multidisciplinary preventive cardiology programme in the west of Ireland. Eur J Prev
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Cardiol. 2014;21:366-376.
21. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk
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reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458-2473. 22. Suaya JA, Shepard DS, Normand ST, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2013; 127:1730-1753. 23. Sandesara PB, Lambert CT, Gordon NF, et al. Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.” J Am Coll Cardiol. 2015;65:389-395.
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ACCEPTED MANUSCRIPT 24. Newby LK, LaPointe NM, Chen AY, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113:203-212.
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25. Ho PM, Magid DJ, Shetterly SM, et al. Medication nonadherence is associated with a broad
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range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155:772-779.
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26. Arnold SV, Spertus JA, Masoudi FA, et al. Beyond medication prescription as performance
J Am Coll Cardiol. 2013;62:1791-1801.
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measures: optimal secondary prevention medication dosing after acute myocardial infarction.
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27. Chow CK, Jolly S, Rao-Melacini P, et al. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes.
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Circulation. 2010;121:750-758.
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28. Brinks J, Fowler A, Franklin BA, et al. Lifestyle modification in secondary prevention: beyond pharmacotherapy. Am J Lifestyle Med. May 30, 2016 doi:
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10.1177/1559827616651402.
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29. Franklin BA, Brinks J. Cardiac rehabilitation: underrecognized/underutilized. Curr Treat Options Cardiovasc Med. 2015;17:62. doi: 10.1007/s11936-015-0422-x. 30. Silberman A, Banthia R, Estay IS, et al. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am J Health Promot. 2010;24:260-266. 31. Aldana SG, Greenlaw R, Salberg A, et al. The effects of an intensive lifestyle modification program on carotid artery intima-media thickness: a randomized trial. Promot. Am J Health Promot. 2007;21:510-516.
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ACCEPTED MANUSCRIPT 32. Zeng W, Stason WB, Fournier S, et al. Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries. Am Heart J.
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2013;165:785-792.
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33. Sangster J, Furber S, Allman-Farinelli M, et al. Effectiveness of a pedometer-based telephone coaching program on weight and physical activity for people referred to a cardiac
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rehabilitation program: a randomized controlled trial. J Cardiopulm Rehabil Prev.
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2015;35:124-129.
34. Maddison R, Pfaeffli L, Whittaker R, et al. A mobile phone intervention increases physical
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activity in people with cardiovascular disease: Results from the HEART randomized controlled trial. Eur J Prev Cardiol. 2015;22:701-709.
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35. Dalal HM, Zawada A, Jolly K, et al. Home based versus centre based cardiac rehabilitation:
10.1136/bmj.b5631.
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Cochrane systematic review and meta-analysis. BMJ. 2010;340:b5631. doi:
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36. Gabbay RA, Bailit MH, Mauger DT, et al. Multipayer patient-centered medical home
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implementation guided by the chronic care model. Jt Comm J Qual Patient Saf. 2011; 37:265-273.
37. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Quarterly. 1996;74:511-544. 38. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effect Clin Pract. 1998;1:2-4. 39. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. National Center for Chronic Disease Prevention and Health Promotion (US) Office
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ACCEPTED MANUSCRIPT Table 1. Research Studies in Community-based Healthy Lifestyle Interventions Name and Date of Study Stanford ThreeCommunity Study, 1981 (Fortmann et al. 1981)6
Location
Population (n*)
Duration Primary Endpoint
Methods
Results
2 communit ies in rural northern California :2 treatment and 1 control
Random sample of men and women 35-59 years of age.
2 years active study; 1 year followup
Dietary education using mass media, selfreported results on questionnaires
Stanford Five-City Project (Farquhar et al. 1990)7
2 treatment and 2 control cities in rural northern California
Cross-sectional 14 years population samples, ages 2574. (n = 1255 in treatment cities)
Changes in knowledge of CV risk factors
23%-34% reductions in dietary cholesterol; 25%-30% reductions in saturated fat. These reductions were significant vs controls. Changes were maintained or further improved in Year 3 Significant reductions with treatment in BP, plasma cholesterol, resting pulse rate, and smoking rate, as well as in CHD risk and total mortality risk
North Karelia Project (Puska et al. 1979)8
North Karelia county, Finland
Representative population samples; men and women ages 26-64 with and without CVD (n = >10,000)
Reductions in smoking, serum cholesterol, and BP
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Cholesterol, body weight
5 years
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General education plus separate risk factor educational campaigns. Program included social learning theory, social marketing, community organization principles; results selfreported in surveys, at baseline and 3 years later Intensive, comprehensive community program
Mean net reduction of CHD of 19% in men and 12% in women.
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DEPLOY Ackermann et al. 2008)11
2 YMCAs in greater Indianapo lis
92 men and women with risk factors for type 2 diabetes
EUROACTI ON (Wood et al. 2008)18
6 pairs of hospitals and 6 pairs of general practices in 8 European countries (interventi on and usual care)
COACH
Communi
40 years
Change in principal CHD risk factors, change in CHD mortality
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Change in weight , blood pressure, Hemoglobin A1c, total cholesterol and HDLcholesterol
6-month lifestyle intervention aimed at behavior change, including diet, weight loss, and physical activity. Changes were sustained at 1 year follow-up
Patients with CVD (n = 3088) or at high risk of developing CVD (n = 2317)
1-year assessme nt; program ran for 3 years 5 months
Weekly workshops and exercise class, prescription of cardioprotective drugs; regular monitoring of risk factors and adherence to treatment
Patients with
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Familybased lifestyle change; BP, lipids, blood glucose to target concentratio ns; smoking cessation; prescription of cardioprotect ive drugs Changes in
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6 months with followup at 1 year
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Analysis of the role of primary prevention and risk factor change in CHD mortality trends over 40 years in the Puska 8 study population. Measure the contribution to CHD mortality trends from three major risk factors (smoking, blood pressure,choleste rol).
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Men and women aged 30-59 years who participated in national FINRISK studies between 1972 and 2012 (n = 34,525)
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Eastern Finland
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Eastern Finland study (Jousilahti et al. 2016)9
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Intensive
CHD mortality decreased by 82% and 84% among men and women, respectivel y, as a result of reductions in three main CV risk factors: smoking, BP, and serum cholesterol Average weight loss of 6% (Interventio n) vs 2% (Control) p <0.001. Greater change on Total Cholesterol -22 vs +6 mg.dL, p = 0.001 Reductions in risk of CVD, including weight loss, mainly through lifestyle changes
Significant
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London, UK
MyAction Galway (Gibson et al. 2014)20
Galway, Ireland
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Patients with coronary disease, high-risk adults and partners (n = 412)
Patients with coronary disease, high-risk adults and partners (n = 556 completing program, 342 at 1-year follow-up)
pharmacologic and lifestyle management
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MyAction UK (Connolly et al. 2011)19
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Urban, rural, and frontier regions of Colorado.
knowledge of CV risk factors
Changes in CVD risk factors and FRS
16 weeks for hospital patients; open ended for general practice patients
16 weeks with 1 year followup
improveme nt in CVD risk profiles; greater understandi ng of CVD
Significant improveme nts in diet, weight, blood pressure, lipids, and FRS Lifestyle Group workshop, Reductions change; motivational in risk of management interviews, CVD of BP, lipids supervised through and blood exercise family glucose, (hospitalized lifestyle prescription patients), changes, of personal record mainly diet cardioprotect card for lifestyle and ive drugs and risk factor physical targets activity Lifestyle Individualized Improveme change; and group nts in management education, lifestyle, of BP, lipids interventions, psychosoci and blood medical al and glucose, management medical prescription risk factors of cardioprotect ive medications
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Colorado Health Hearts Solution (CHHS) (Krantz et al. 2013)16
CVD, type 2 months diabetes, hypercholesterol emia or hypertension or levels of LDL-C, BP, or HbA1c in excess of goals in national guidelines (n = 525) Medically ≥3 underserved months populations (n = 698; 15% at high risk)
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Trial (Allen et al. 2011)15
Risk factor screening and motivational interviewing to facilitate behavior change
BP, blood pressure; CHD, coronary heart disease; COACH, Community Outreach and Cardiovascular Health; CV, cardiovascular; CVD, cardiovascular disease; DPP, diabetes prevention program; FRS, Framingham Risk Score. *n where available.
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ACCEPTED MANUSCRIPT Table 2. 1-Year Results: Patient-Centered Medical Home36
Baseline Mean Percentage
Value at 1 year
Eye exam
30.4
41.2*
Foot exam
50.6
Microalbumin
62.7
Pneumonia vaccination
25.5
Smoking cessation
57.0
Evidence-based treatment
Baseline Mean
Value at 1 year
Aspirin
50.8
64.2*
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Evidence-based screening
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69.0*
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69.1*
Statin
57.5*
42.3
55.6*
50.5
70.0*
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Self-management goal
71.0*
36.1
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ACE/ARB
42.4*
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ACE, angiotesin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; *Indicates a significant difference at Year 1 compared to baseline (p <0.05).
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ACCEPTED MANUSCRIPT Figure 1.
Interventions of Multidisciplinary Healthcare Team in MyAction Program (19)
Copyright of Medinews (Cardiology) Limited, reproduced with permission' 12/29/16.
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At the initial assessment, patients and their partners were seen together and were then individually assessed by members of the multidisciplinary team for smoking habit; diet; weight, height, body mass index, and waist circumference; physical activity levels; functional capacity; psychosocial measures; blood pressure; fasting lipids and glucose; and use of cardioprotective medications. The 16-week progam included individual follow-up, a weekly educational workshop and supervised exercise sessions, in which all members of the multidisciplinary team took part. A weekly meeting between the multidisciplinary team and cardiologist reviewed lifestyle, risk factors and therapeutic goals. The nurse and cardiologist followed established protocols for risk factor management.
Figure 1 Copyright
of Medinews (Cardiology) Limited, reproduced with permission' 12/29/16. 30