Cover Story

Psychology helps heal metaphorical broken hearts, but what can it do for real ones? It can help keep them from breaking in the first place through behavioral interventions for major heart disease risk factors such as smoking, physical inactivity and diabetes.

Two major preventive ingredients are proving important: Focus on the constructive-what people can do to help themselves-and follow up, says psychologist Elyse Park, PhD, an assistant psychiatry professor at Harvard Medical School.

"It's about building up efficacy and motivating them to see things positively," she says.

Park also believes that health professionals shouldn't wait for people at risk for heart disease to come find them. "The patients who come forward are more successful, but sometimes being reached out to can really help patients," she notes.

Up in smoke

Cigarette smoking increases the risk of cardiovascular disease by itself and can also interact with other factors to further increase risk, according to the American Heart Association. Smoking increases blood pressure, decreases exercise tolerance, increases the tendency for blood to clot and decreases "good" cholesterol. Taking into consideration all of these effects, smoking accounts for almost 440,000 deaths annually.

So how do you get people to quit? A combination of behavioral change counseling and pharmaceutical assistance works best, says Park, who has worked with cancer patients and survivors, expectant and new parents and other groups who are trying to quit smoking. Interventions should be targeted to an individual's barriers, she says. "Try to figure out what motivates them to smoke, what is their quit history and their support system, and help them set goals," Park says.

For instance, in a 2006 study published in Obstetrics & Gynecology (Vol. 108, No. 1, pages 83-92), Park and her team found that a telephone intervention targeted specifically at pregnant women was more effective than an untargeted method in light smokers or those who had previously tried to quit. However, the intervention was not more effective in heavy smokers, who likely need additional strategies such as pharmaceutical therapy or more intensive counseling.

Events like a heart attack, cancer diagnosis or pregnancy can also be what Park calls "teachable moments" which can give extra motivation. The counseling in the cessation therapy would target condition-specific issues such as the negative effects that smoking has on a fetus or how quitting smoking can reduce the risk of a repeat heart attack.

On the move

Physical activity helps reduce the risk of heart disease by improving blood circulation throughout the body, reducing cholesterol levels, controlling blood pressure and reducing weight gain, according to the American Heart Association. However, only about 30 percent of Americans 18 or older engage in 30 minutes or more of leisure-time physical activity five or more times a week, recent Centers for Disease Control and Prevention estimates suggest. Health professionals are working to increase that number through a variety of means.

One approach is to teach a successful exercise regimen involving planning and self-regulation, says Martina Kanning, a sports psychology researcher at the University of Stuttgart.

"You have to plan your [exercise] actions-when you will do it, and what you will do," notes Kanning, who was one of the contributors tothe recent APA book release "Contributions Toward Evidence-Based Psychocardiology: A Systematic Review of the Literature" (see "One heart-many threats").

Behavioral techniques can be useful in addressing this, but future research should determine what works consistently, she says. One approach is to give people specific small steps that they can take to start improving their fitness and well-being, says John Jakicic, PhD, a professor of exercise physiology at the University of Pittsburgh. Jakicic is running a citywide fitness campaign, "America on the Move in Pittsburgh."

It's based on a national initiative pioneered by the America on the Move Foundation, which was co-founded by James O. Hill, PhD, a physiological psychologist. The foundation has conducted several small studies suggesting that setting small goals can have appreciable results. For instance, a 2004 study in the Journal of Physical Activity and Health (Vol. 1, No. 3, pages 181-190) indicated that a community-based effort to encourage people to take an additional 2,000 steps a day can increase physical fitness levels. A 2006 study in Obesity (Vol. 14, No. 8, pages 1392-1401) showed that families with obese children who increased their steps and altered their food intake by eating at least two servings of cereal a day were able to prevent weight gain.

The goal of America on the Move is activity, and each community does it a little differently. Jakicic sees Pittsburgh's as the most progressive because of a community coalition he's built that includes big business, local grocery stores, restaurants, the parks conservancy and the media. He also hopes to involve primary-care physicians and local school districts.

"Our goal is to take more simple steps to make people more healthy, because Pittsburgh is a pretty unhealthy city," says Jakicic. "[We are saying] here is how you can eat healthy, this is how you can be active."

The coalition has used the media to get out the message about Pittsburgh's parks and bike trails and other ways to add 2,000 steps a day. "One time around the football field [at the University of Pittsburgh] is 2,000 steps," Jakicic says. "We also point out various landmarks-from this landmark to that landmark is 2,000 steps," he adds. "We also stage public events where we do something simple like go on a walk during the lunch hour."

The coalition also worked with the city's largest grocery chain to develop a "healthy foods" section in all of its stores. The chain is also developing plans for stores that will be like the organic market chain Whole Foods.

Defeating diabetes

In the United States, the 20.8 million people who have diagnosed and undiagnosed diabetes are two to four times more likely to die from heart disease than those without the condition, the American Diabetes Association (ADA) estimates. In addition, ADA estimates that about 54 million Americans have prediabetes, a condition in which glucose levels are elevated, but not yet high enough to be diagnosed as diabetes. Research has indicated that these elevated levels may already be causing damage-especially to the heart and circulatory system.

The good news? A 2002 large-scale study of the Diabetes Prevention Program, published in the New England Journal of Medicine (Vol. 346, No. 6, pages 393-403), has shown that the onset of diabetes can be delayed or even prevented through lifestyle interventions. Those same interventions can also help keep diabetes under control.

"We had a 58 percent reduction in diabetes risk with lifestyle treatment," says psychologist Elizabeth Venditti, PhD, one of the principal investigators on the Diabetes Prevention Program.

The lifestyle treatment consisted of modifying diet to achieve a seven percent body weight loss and performing 150 minutes of exercise a week. "I think the fact that the goals were very clear and there was a sense of 'this is what you can achieve' made it more effective," says Venditti.

The participants received training in keeping a food diary and monitoring calorie intake, weighing themselves regularly to make the connection between behavior and results, reading food labels, and putting together an activity program. They also worked on overcoming barriers and learning problem-solving skills such as how to make healthy choices when eating in a restaurant or to avoid the urge to overeat on social occasions. Participants were also prepared for regaining weight, and how to get back on track after that happens. Follow up was also crucial, says Venditti.

"We created this place where people knew they could be held accountable," she says.

Getting such interventions to the neediest patients is the next challenge?, says Venditti.

"We have the behavioral methods, but access and delivery are lagging behind," stresses Venditti. Health-care professionals now needs to focus on how to create a health-care environment where people will have a place to go for "lifestyle" checkups once they get going on these kinds of interventions, she adds.

"There needs to be long-term contact," she asserts. "It doesn't have to be frequent- just something where the person feels accountable."