Arq Bras Cardiol. 2015 May; 104(5): 347–355.
Cardiovascular diseases are the current leading causes of death and disability
To assess the effects of a basic educational program for cardiovascular prevention
in an unselected outpatient population.
All participants received an educational program to change to a healthy lifestyle.
Assessments were conducted at study enrollment and during follow-up. Symptoms,
habits, ATP III parameters for metabolic syndrome, and American Heart
Association’s 2020 parameters of cardiovascular health were assessed.
A total of 15,073 participants aged ≥ 18 years entered the study. Data
analysis was conducted in 3,009 patients who completed a second assessment. An
improvement in weight (from 76.6 ± 15.3 to 76.4 ± 15.3 kg, p =
0.002), dyspnea on exertion NYHA grade II (from 23.4% to 21.0%) and grade III
(from 15.8% to 14.0%) and a decrease in the proportion of current active smokers
(from 3.6% to 2.9%, p = 0.002) could be documented. The proportion of patients
with levels of triglycerides > 150 mg/dL (from 46.3% to 42.4%, p < 0.001) and LDL cholesterol > 100 mg/dL (from 69.3% to 65.5%, p < 0.001) improved. A ≥ 20% improvement of AHA 2020 metrics at the level graded as poor was found for smoking (-21.1%), diet (-29.8%), and cholesterol level (-23.6%). A large dropout as a surrogate indicator for low patient adherence was documented throughout the first 5 visits, 80% between the first and second assessments, 55.6% between the second and third assessments, 43.6% between the third and fourth assessments, and 38% between the fourth and fifth assessments.
A simple, basic educational program may improve symptoms and modifiable
cardiovascular risk factors, but shows low patient adherence.
Keywords: Health Behavior, Life Style, Prevention, Obesity, Risk Factors, Health Education
According to estimations of the World Health Organization, cardiovascular diseases are
the current leading causes of death and disability globally, with an increasing tendency
and negative projection for 2030. Although a large proportion is preventable, their
incidence continues to increase mainly because preventive measures are
Several trials have reported the effects of lifestyle intervention programs on high-risk
populations. Some have shown a significant decrease in the incidence of diabetes in
individuals with impaired glucose tolerance2. Others have reported the beneficial effects of lifestyle
modification on blood pressure control3. Lifestyle interventions seem to be at least as effective as
drugs4. Therefore, lifestyle
modification, long considered the cornerstone of interventions, is extremely important
to reduce the burden of chronic diseases1.
In the light of this epidemic scenario, government health policies in industrialized
countries are focusing on programs to modify cardiovascular risk factors5. Smoking bans to protect citizens from
the effects of second-hand smoke have been successfully implemented in many countries,
showing positive effects even in this short period of time6,7. However,
achievements considering other modifiable risk factors remain discouraging8. Furthermore, comprehensive and complex
educational programs lack a widespread implementation in the general population, and are
related to lesser patient compliance9-11. Therefore, the aim of this study was to
assess the practicability of a basic educational program to turn established behaviors
into a healthy lifestyle in an urban outpatient population, as well as to define the
effects of these changes on symptoms and modifiable cardiovascular risk factors.
Design and study population
The AsuRiesgo (acronym from Asuncion modificacion de factores de Riesgo
cardiovascular) study is a case series type prospective trial, in which all
participants received the same intervention – an educational program to increase
awareness on cardiovascular risk factors, and, based on this, to change usual habits
into a healthy lifestyle. The cohort included an unselected outpatient population
aged ≥ 18 years old attending a high-output tertiary clinic in an urban
setting in Asuncion, Paraguay.
Patients in all waiting areas of the hospital were invited to participate. All
assessments were conducted at study enrollment and at every visit during follow-up.
Participants were asked to attend follow-up examinations every 6 months. The
institutional ethics committee approved the study protocol and all patients provided
written informed consent. This study is registered on ClinicalTrials.gov under the
Assessment of symptoms and habits
Personal and family information was obtained. Exertional dyspnea and chest pain were
graded according to the New York Heart Association (NYHA) functional classification
and the Canadian Cardiovascular Society (CCS) classification, respectively. History
of known coronary artery disease and/or diabetes mellitus was documented.
Prevalence of parameters of cardiovascular health metrics, as defined by the American
Heart Association’s (AHA) 2020 Strategic Impact Goals Committee was assessed, and
ideal, intermediate or poor levels were calculated5. Relative change after education to a healthy
lifestyle was estimated for each of the 4 health behaviors (smoking, diet, physical
activity and body mass) and 3 health factors (plasma glucose, cholesterol levels and
Smoking habit was extensively interrogated. However, only the aspects defined by the
American Heart Association’s 2020 Strategic Impact Goals Committee5 were considered for analysis. Current
smokers were classified as being in the group with a poor level of cardiovascular
health; those who quit smoking < 12 months, as intermediate; and non-smokers as well as those who quit smoking ≥ 12 months, as ideal.
Dietary behavior was defined qualitatively according to the daily intake of three
groups of foods: meats/animal fats, vegetables/fruits and sugar/carbohydrates. The
degree of consumption was assessed for each group as “none”, “low”, “moderate” or
“high”. A simple healthy diet score was built accordingly, and scores from 1-3 points
were considered as “poor”, from 4-6 points as “intermediate”, and from 7-9 points as
The level of daily physical activity was classified as sedentary behavior, when not
even a short recreational-type walk was achieved; moderate, when at least 30 minutes
of a recreational-type walk at moderate intensity was achieved daily; and important,
when ≥ 30 minutes of vigorous recreational walk or sports were achieved.
Participants were classified as having a poor, intermediate or ideal level,
The daily level of psychological stress was classified subjectively as mild or
absent, moderate or important.
Assessment of anthropometric and laboratory parameters
All parameters were assessed at inclusion and at every follow-up visit. Body weight,
height, body mass index (BMI), abdominal circumference and blood pressure, as well as
standard laboratory parameters including triglycerides, total cholesterol, HDL and
LDL cholesterol and fasting plasma glucose were assessed as described in another
report12. In addition, the
prevalence of AHA parameters of cardiovascular health metrics was assessed5.
Education to a healthy lifestyle
All participants attended one educational workshop at the beginning, and were
encouraged to participate in similar workshops at every visit during follow-up.
Informative material was compiled from recommendations published in another
Basic knowledge on cardiovascular diseases and risk factors was addressed. Targets
were directed to quit smoking, switching to a healthy diet, avoiding sedentary
lifestyle and working on reducing daily psychological stress. The following
strategies were undertaken to reach these goals: 1) tips on how to quit smoking; 2)
aspects concerning a healthy diet, with suggestions for everyday life; 3) suggestions
on how to implement a daily physical exercise program; and 4) useful strategies for
reducing daily psychological stress.
Smoking cessation: patients were advised of the value of stopping and
the risks to health of continuing smoking. It was suggested to set a date to stop and
stop completely on that day, to review experiences concerning measures that helped or
that hindered, and to ask family members and friends for their support. No nicotine
replacement drugs were used12.
Healthy diet: patients were asked to eat moderately; to reduce
consumption of meats, especially red meats; to avoid consumption of animal fats and
hydrogenated vegetable oils; to switch to daily meals with emphasis on vegetables and
fruits; to reduce daily salt intake; and to reduce consumption of sugar and refined
wheat products, switching to whole-wheat products instead.
Physical activity: patients given suggestions to avoid a sedentary
lifestyle by accomplishing at least a 30-minute recreational daily walk. They were
motivated to start at a moderate pace, and to increase speed progressively to a level
as vigorous as possible. Furthermore, they were stimulated to practice aerobic sports
according to their possibilities13.
Psychological stress: physicians in charge of the study addressed coping
with daily psychological stress. Possible causes such as occupational, familial
and/or social were examined and helpful measures were suggested. A professional
psychological support was provided as required.
Workshops were conducted by physicians and nurses trained for this purpose. A close
supervision and coaching was done by physicians in charge of this study. Treatment
was further managed by the corresponding referring physician. No change in
medications was made as part of the study. Patients were merely told to follow
strictly the indications of their treating physician. Further written material, as
well as current information related to the study were posted on the website:
All analyses were performed with the use of SAS version 9.1 (SAS Institute, Cary,
NC). Continuous variables are presented as means and standard deviations (SD).
Frequencies and percentages are used to describe categorical variables. To test for
differences between the baseline and the second assessment, paired t-tests for
continuous data and the McNemar’s test or the Bowker’s test for categorical data were
applied. No adjustments for multiple testing were performed, since this was an
exploratory data analysis. Patient dropout as a surrogate indicator for adherence was
examined throughout the first 5 visits. A two-sided p-value of less than 0.05 was
considered statistically significant.
The recruitment of patients was conducted in a continuous manner between May, 2006 and
May, 2012. Approximately 40,000 individuals were invited to participate in this period.
A total of 15,073 patients gave written informed consent and entered the study.
Baseline characteristics of the patient population
Anthropometric characteristics, personal and familial disease history and symptoms
are presented in . Female prevalence
in this population was high – more than double that of males.
|Age, yrs||50.8 ± 15.1|
|Women, n (%)||10,377 (69)|
|Weight, kg||77.3 ± 16.0|
|Body mass index, n (%)|
|< 25 kg/m2||2,966 (19.7)|
|25-29 kg/m2||5,583 (37.0)|
|> 30 kg/m2||6,524 (43.3)|
|Personal history of CAD, n (%)||390 (2.6)|
|Known diabetes mellitus, n (%)||2,063 (13.7)|
|Family history of CAD, n (%)||819 (5.4)|
|Dyspnea, n (%)||5,221 (34.7)|
|NYHA I||527 (3.5)|
|NYHA II||2,743 (18.2)|
|NYHA III||1,951 (12.9)|
|Angina pectoris, n (%)||2,388 (15.8)|
|CCS I||407 (2.7)|
|CCS II||1,271 (8.4)|
|CCS III||710 (4.7)|
The prevalence of known coronary artery disease and diabetes mellitus was low, and
family history of coronary heart disease was present in 5.4% of the study population.
Patients stated having shortness of breath on exertion, with a NYHA functional
classification grade II in approximately 18% and NYHA grade III in approximately 13%
of patients. The prevalence of angina pectoris on exertion was lower, with
approximately 8% of patients being classified as CCS II and 5% as CCS III.
Dropout of participants during follow-up
Patients were requested to attend a follow-up visit by telephone or
Short-Message-Service (SMS) if they did not come spontaneously to the visit scheduled
for 6 months after the first assessment. However, although striving efforts were
undertaken, a large dropout rate could be documented throughout the first 5 visits,
80% between the first and second assessments, 55.6% between the second and third,
43.6% between the third and fourth, and 38% between the fourth and fifth assessments.
The median time span between the first and second assessments was 10 months
(25th, 75th percentiles, 7 to 21 months). Patient flow and
dropout rate during follow-up throughout the first five assessments were documented
Change in parameters after education to a healthy lifestyle
Comparative analysis between the first and second assessments was carried out in
patients for whom the information on medical history and habits, physical examination
and laboratory tests had been assessed at both visits (n = 3,009).
Anthropometrics, symptoms and habits
A slight but significant decrease in weight (from 76.6 ± 15.3 kg to 76.4
± 15.3 kg, p = 0.002) and body mass index (from 30.2 ± 5.6 kg/m² to
30.1 ± 5.6 kg/m², p=0.004) could be documented at the second assessment after
education to a healthy lifestyle ().
The proportion of patients with dyspnea on exertion NYHA grade II and grade III was
also lower at the second visit (from 23.4% to 21.0%, and from 15.8% to 14.0%,
respectively). The proportion of patients with angina pectoris on exertion decreased
as well, but the differences were not statistically significant.
|Variable||Baseline||Second Assessment||P value|
|Weight, kg||76.6 ± 15.3||76.4 ± 15.3||0.002 *|
|Body mass index, kg/m2||30.2 ± 5.6||30.1 ± 5.6||0.004 *|
|Dyspnea, n (%)|
|No||1,699 (56.6)||1,843 (61.3)|
|Yes||1,310 (43.5)||1,164 (38.7)||< 0.001 †|
|NYHA I||131 (4.4)||111 (3.7)|
|NYHA II||705 (23.4)||632 (21.0)|
|NYHA III||474 (15.8)||421 (14.0)|
|Angina pectoris, n (%)|
|No||2,547 (84.6)||2,580 (85.8)|
|Yes||462 (15.4)||428 (14.2)||0.143 †|
|CCS I||77 (2.6)||69 (2.3)|
|CCS II||231 (7.7)||224 (7.4)|
|CCS III||154 (5.1)||135 (4.5)|
|Smoking, n (%)|
|No||2,110 (70.1)||2,129 (70.8)|
|Yes||899 (29.9)||880 (29.2)||0.110 †|
|No||2,900 (96.4)||2,923 (97.1)|
|Yes||109 (3.6)||86 (2.9)||0.002 †|
|No||2,196 (73.0)||2,199 (73.1)|
|Yes||813 (27.0)||810 (26.9)||0.772 †|
|No||2,343 (77.9)||2,309 (76.7)|
|Yes||666 (22.1)||700 (23.3)||< 0.001 †|
|Diet, n (%)|
|Poor||983 (32.7)||690 (22.9)||< 0.001 ‡|
|Intermediate||1,785 (59.3)||1,901 (63.2)|
|Ideal||241 (8.0)||417 (13.9)|
|Physical activity, n (%)|
|No||1,626 (54.0)||1,478 (49.2)||< 0.001 ‡|
|Some||1,378 (45.8)||1,519 (50.5)|
|Frequent||5 (0.2)||9 (0.3)|
|Psychological stress level, n (%)|
|Mild or absent||604 (42.1)||453 (46.5)||0.006 ‡|
|Moderate||646 (45.0)||391 (40.1)|
|Important||185 (12.9)||131 (13.4)|
The proportion of current active smokers decreased (from 3.6% to 2.9%, p = 0.002).
There were also fewer passive smokers, but the difference here was not statistically
significant. The proportion of former smokers increased correspondingly (from 22.2%
to 23.3%). The proportion of patients with a sedentary lifestyle decreased (from
54.0% to 49.2%), while an increase in daily physical activities could be documented
correspondingly (from 45.8% to 50.5%). Although the level of psychological stress in
patients who described it as “important” increased slightly after education to a
healthy lifestyle (from 12.9% to 13.4%); the level of stress improved in the group of
patients with “mild or absent” (from 42.1% to 46.5%) and with “moderate” intensity
(from 45.0% to 40.1%).
ATP III criteria for metabolic syndrome and LDL cholesterol
The proportion of patients with any particular parameters for metabolic syndrome
showed minimal, but statistically not significant differences at the second
assessment (; for brevity, subgroups
are not shown). However, significant improvement in lipid profiles could be
documented, with a decrease in the proportion of patients with triglycerides > 150
mg/dL (from 46.3% to 42.4%, p < 0.001), especially in patients ≥ 60 years old. Additionally, a mild improvement in HDL-cholesterol levels could be observed in men, with a significant decrease in the prevalence of HDL < 40 mg/dL in the age group between 40 and 49 years of age (from 29.7% to 20.4%, p = 0.009). Tendency to a lower prevalence of low HDL levels was found only in the group of female patients between 60 and 69 years of age (from 46.5% to 43.4%, p = 0.084).
|Variable||Baseline||Second Assessment||P value|
|Women > 88 cm, n (%)||1,824 (79.6)||1,827 (79.7)||0.845|
|Men > 102 cm, n (%)||302 (42.1)||299 (41.7)||0.763|
|Triglycerides > 150 mg/dL, n (%)||1,382 (46.3)||1,268 (42.4)||< 0.001|
|Women < 50 mg/dL, n (%)||978 (43.6)||1,018 (45.2)||0.250|
|Men < 40 mg/dL, n (%)||187 (26.7)||175 (24.9)||0.280|
|Systolic > 130 mmHg, n (%)||1,352 (44.9)||1,318 (43.8)||0.279|
|Diastolic > 85 mmHg, n (%)||941 (31.3)||913 (30.3)||0.362|
|Fasting glucose > 100mg/dL, n (%)||591 (19.8)||603 (20.2)||0.492|
|LDL cholesterol > 100 mg/dL, n (%)||2,039 (69.3)||1,937 (65.5)||< 0.001|
Improvement was also found in LDL-cholesterol levels > 100 mg/dL (from 69.3% to
65.5%, p < 0.001). This decrease was statistically significant in the age groups between 50-59 years of age (p = 0.03) and 60-69 years of age (p = 0.004).
AHA parameters of cardiovascular health metrics
Changes in the prevalence of parameters of cardiovascular health metrics, as defined
by the American Heart Association’s 2020 Strategic Impact Goals Committee5 after education to a healthy lifestyle
are depicted in . Relative improvement
in parameters of cardiovascular health are presented as percentage of change for each
of the 4 health behaviors (smoking, diet, physical activity, body mass) and 3 health
factors (plasma glucose, cholesterol levels, blood pressure).
|Variable||Baseline||Second Assessment||% Change||P value|
|Poor||109 (3.6)||86 (2.9)||-21.1||< 0.001|
|Intermediate||32 (1.1)||28 (0.9)||-12.5|
|Ideal||2,868 (95.3)||2,893 (96.2)||0.9|
|Poor||983 (32.7)||690 (22.9)||-29.8||< 0.001|
|Intermediate||1,785 (59.3)||1,901 (63.2)||6.5|
|Ideal||241 (8.0)||417 (13.9)||73.0|
|Poor||1,626 (54.0)||1,478 (49.2)||-9.1||< 0.001|
|Intermediate||1,378 (45.8)||1,519 (50.5)||10.2|
|Ideal||5 (0.2)||9 (0.3)||80.0|
|Poor||1,376 (45.7)||1,356 (45.1)||-1.5||0.323|
|Intermediate||1,166 (38.8)||1,171 (38.9)||0.4|
|Ideal||467 (15.5)||481 (16.0)||3.0|
|Poor||317 (10.6)||303 (10.2)||-4.4||0.046|
|Intermediate||704 (23.6)||745 (25.0)||5.8|
|Ideal||1,965 (65.8)||1,937 (64.9)||-1.4|
|Poor||674 (22.6)||515 (17.2)||-23.6||< 0.001|
|Intermediate||935 (31.3)||900 (30.1)||-3.7|
|Ideal||1,377 (46.1)||1,574 (52.7)||14.3|
|Poor||1,187 (39.4)||1,131 (37.6)||-4.7||0.348|
|Intermediate||1,185 (39.4)||1,233 (41.0)||4.1|
|Ideal||637 (21.2)||645 (21.4)||1.3|
Significant improvement in some parameters were documented. A ≥ 20%
improvement was found at the level graded as poor for smoking
(-21.1%), diet (-29.8%), and cholesterol level (-23.6%). Minor changes at the same
level were also observed for physical activity (-9.1%), body weight (-1.5%), plasma
glucose (-4.4%), and blood pressure (-4.7%). Improvements were also found at the
level grade as ideal, especially considering healthy diet (+73%) and
cholesterol levels <200 mg/dL (+14.3%).
In this prospective study, we could show that a simple basic educational program may
improve symptoms and modifiable cardiovascular risk factors in an unselected outpatient
population. An improvement in weight and dyspnea on exertion, as well as a decrease in
the proportion of current active smokers were documented. The proportion of patients
with high levels of triglycerides and LDL cholesterol improved. In addition, a ≥
20% improvement of the American Health Association 2020 metrics was found for smoking,
diet and cholesterol level. However, the low adherence, as evidenced by a high dropout
rate of participants throughout the study follow-up, was documented.
Only minimal changes in weight (mean weight loss of 0.2 kg) and no significant changes
in abdominal circumference were found in this study, conducted in a non-coached
approach. Similar changes could be observed in prospective studies when patients were
included in study arms in which the intervention consisted only in consultations with a
dietitian and the use of self-help resources14,15. However, patients
included in intervention arms with an intensive, coached program toward weight
reduction, delivered in a weekly basis, showed a much higher decrease in body weight
(mean weight loss of 4 kg)14,15. Changes in diet and sedentary life
habits in the last decades have led to a significant decline in the global health
profiles of the population. Specific dietary and lifestyle factors have been shown to be
independently associated with long-term weight gain, including changes in the
consumption of specific foods and beverages, reduced physical activity, alcohol
consuption, television watching, and smoking16. Moreover, diet quality in patients with known vascular disease
or diabetes mellitus has a strong association with cardiovascular disease (CVD)
outcomes. A higher-quality diet was associated with a lower risk of recurrent CVD events
among people ≥ 55 years of age17.
Randomized lifestyle interventions for cardiovascular risk reduction have proven to be
feasible and effective18-23. However, translating findings from
extensively resourced trials, focused on highly selected populations, into a real-life
setting in which resources are limited and populations are more heterogeneous is a
The expectation of long-term positive effects of the adherence to a healthy lifestyle
has been confirmed in few studies6,10,22. Individuals who had newly adopted a healthy lifestyle in middle age
experienced a prompt benefit of lower rates of cardiovascular disease and mortality. A
midlife switch to a healthy lifestyle that includes a diet of at least 5 daily fruits
and vegetables, exercise, maintaining a healthy weight, and not smoking resulted in a
substantial reduction in mortality and cardiovascular disease over the subsequent 4
However, it also has been shown that the acceptance of advice on diet and physical
activity and patient actions remain suboptimal9,10. Overall adherence to
medical advice, independent of a therapeutic of preventive approach, has been reported
to be low in the general population. In a recent meta-analysis, approximately one third
of patients who had had myocardial infarction and approximately one half of those who
had not had myocardial infarction did not adhere to effective cardiovascular preventive
treatment24. In our study, a
large interest of patients in taking part of the study was followed by a very
discouraging, massive decline in further participation in the follow-up examinations
(). Higher participation could not be
achieved in spite of repeated invitations by phone, e-mail and short-message-system
reminders of the next appointment.
Education for cardiovascular prevention is a very important element of the strategies
toward improving cardiovascular health in the community. However, the individual
perception of health targets may be limited, and preventive measures may therefore be
difficult to follow.
Interpretation of the results of this study is limited by its design as a case-series
type prospective trial. Contrary to case-control studies, only
before-after analysis of parameters was possible here.
A simple, basic educational program may improve symptoms and cardiovascular risk factors
in an unselected outpatient population, when conducted in a non-coached approach.
However, patient adherence remains an important issue to be addressed.
Conception and design of the research: Chaves G, Britez N, Gonzalez G, Oviedo G,
Chaparro V, Mereles D. Acquisition of data: Chaves G, Britez N, Oviedo G, Chaparro V.
Analysis and interpretation of the data: Chaves G, Britez N, Mereles D. Statistical
analysis: Munzinger J, Uhlmann L, Bruckner T, Kieser M, Mereles D. Obtaining
financing: Britez N. Drafting of the manuscript: Chaves G, Britez N, Mereles D.
Critical revision of the manuscript for intellectual content: Chaves G, Britez N,
Gonzalez G, Achon O, Kieser M, Mereles D, Katus HA. Supervision / as the major
investigator: Chaves G, Mereles D.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Sources of Funding
There were no external funding sources for this study.
This study is not associated with any thesis or dissertation work.
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