Specialty Corner: Clinician Strategies for Facilitating Lifestyle Changes During COVID-19 and Beyond

Despite substantial improvements in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of death worldwide.(1,2) Continued prevalence of ASCVD is attributable to behaviors that impact control of known risk factors such as dyslipidemia, hypertension, pre-diabetes, diabetes, obesity, and metabolic syndrome. (4) Conversely, behaviors that lower ASCVD risk factors such as abstinence from smoking, being physically active, maintaining ideal body mass index, and consuming a cardio-protective diet form integral part of prevention and treatment of ASCVD.(5) Social determinants of health are additional factors that impact ASCVD and these added burdens are further impacted by race, gender, and ethnicity in the U.S.(3) While positive health behaviors are associated with lower risk of developing ASCVD, implementing and maintaining these behaviors can be challenging.(6) Optimal prevention strategies need to be patient-centered and should empower, engage, and motivate patients at an individual level to stimulate a process of behavior change (7) which then have the potential for sustained positive change.

The current public health crisis caused by the outbreak of Sars-Cov-2 has imposed new challenges at different levels affecting psychosocial wellbeing of individuals and communities.(8) Social distancing and selfisolation - two key elements in limiting the spread of virus (9) - have led to increased sedentary behaviors and increased caloric intake.(10) Studies highlighting the impact of COVID-19 on dietary behaviors point to the fact that negative emotions (stress, fear, anxiety, boredom) and stressors (food insecurity) secondary to the COVID 19 pandemic can be associated with intake of increased calories as well as a more atherogenic diet high in saturated fats, refined carbohydrates, and added sugars.(11-13)

Top diet strategies recommended for prevention and management of ASCVD include:

1) Reducing Saturated Fat intake to less than 5-6% total calories in patients at risk of ASCVD.
2) Avoiding or minimizing trans-fat intake.
3) Incorporating Dietary Approaches to Stop Hypertension (DASH), Mediterranean-style and vegetarian-based eating patterns.

Reduce Saturated Fat intake to less than 5-6% total calories in patients at risk of ASCVD.
There is strong evidence suggesting that saturated fats have the most atherogenic impact on lipid levels.(14) Iso-caloric replacement of these fats with polyunsaturated fatty acids (PUFAs) is associated with significant reduction in low density lipoprotein cholesterol (LDL-C), which is a focus for ASCVD prevention. (14) Caloric intake with high saturated fat (e.g., meat, full-fat dairy products, and tropical oils such as coconut and palm oil) should be limited to achieve ~5-6% of energy from saturated fats. This translates to ~11-13 gm of saturated fat on a 2,000 kcal/d diet pattern. This decrease in saturated fats should be accompanied with an increase in polyunsaturated fats
contained in canola oil, corn oil, soybean oil, peanut oil, safflower oil, sunflower oil, and walnuts.(5)

Avoid or minimize trans-fat intake.
Aside from saturated fats, trans-fats are also strong determinants of elevated LDL cholesterol. Specifically, industrial trans-fatty acids, produced by chemical and enzymatic action for use in partially hydrogenated vegetable oils, have adverse effects on LDL-C.(14) A variety of processed foods, including margarines, baked goods, and commercial deep-fried foods are high in industrial trans fatty acids.(15) Higher intake of trans-fat in the diet has shown to increase coronary heart disease (CHD) risk by almost 21%.(16) Replacing trans fats in the diet by ~2% total calories with PUFAs, MUFAs, and even SFAs reduces CHD risk by 24%, 21%, and 17%, respectively.(17) This robust association of trans-fats with CHD has prompted the Food and Drug Administration (FDA) to make legislative changes which has resulted in significant decline in intake of trans-fats in the US population in the past 2 decades.(15)

Incorporate the Dietary Approaches to Stop Hypertension (DASH), the Mediterranean-style and the vegetarian diet eating patterns.
A heart-healthy diet pattern emphasizes vegetables, fruits, and whole grains and incorporates low-fat or fat-free dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts. It limits intake of sweets, sugar-sweetened beverages, salty or highly-processed foods, and fatty or processed meats.(5) These recommendations should be adapted to meet appropriate calorie requirements and personal and cultural food preferences and incorporate relevant medical nutrition therapy to address any risk factors or medical conditions that individuals may exhibit.(5) There is extensive evidence in support of the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, the original Mediterraneanstyle diet pattern and the vegetarian diet pattern for successfully accomplishing these goals.(5) These diet patterns when implemented within caloric needs provide <7% saturated fats and are low in trans fats intake.(5)

Strategies for facilitating dietary changes:
Most Americans in the United States today do not meet the current lifestyle guidelines, specifically dietary guidelines set forth by the American Heart Association for CVD risk reduction and management.(18) Most clinicians do not adequately assess or counsel patients about their food and beverage intake because of clinical constraints and barriers which can be overcome as follows:

• Dietary assessment: is essential for achieving dietary adherence by promoting self-efficacy among patients. Clinicians should aim to identify inconsistencies and gaps through diet assessments and offer targets for modifications based on personal preferences for effective intervention. Several commercial and non-commercial tools for diet assessment and self-monitoring are available (See Table 1 for noncommercial tools).
   o Scoring systems based on nutrient/recommended food intake and diet patterns have been developed to evaluate diet intake and provide fair assessment of diet quality and adherence and are associated with lower risk of ASCVD.(19) Commercial and         noncommercial tools are available to help obtain objective assessment of diet quality and adherence and also support maintaining exercise regimen. Clinicians should aim at using these tools routinely for behavior change and consistent follow-ups should
   be emphasized for maintaining behavior change.
• Dietary recommendations: Once diet assessment is completed, engage the patient in diet education and provide evidence based dietary recommendations. For this the clinician should discuss eating patterns that offer healthier choices while keeping patient preferences in mind. Providing examples of specific foods or food groups that should be emphasized and de-emphasized is a good approach to promote dietary change and adherence – see Table 2. Clinicians should emphasize the importance of exercise as it is crucial complementary element to hearthealthy lifestyle.
• Behavior modifications: Developing actionable steps/goals for improvement promotes diet adherence. Core elements of behavior change to target for successful behavior change include improving self-efficacy, self-regulation (self-monitoring, goal setting, relapse prevention, reinforcement, stimulus control) and social support.(7,20) Self-regulatory skills are particularly important for behavior change and self-efficacy, outcome expectations, and social support are associated with maintenance of healthy behaviors.(20) Often, patients lack selfregulatory skills and clinicians should focus on promoting the development of these skills which will enhance self-efficacy and thereby promote positive behavior change. Table 3 highlights some of the self-regulatory skills that clinicians should focus to develop in patients.
   o Self-efficacy is one’s selfconfidence in the ability to perform the targeted behavior. For example, “Include 1 cup of vegetable daily in my diet OR I will go for a walk 5 days a week for 30 minutes.”
   o Self-regulation is one’s ability to control and regulate action related to the behavior. These include self-monitoring (E.g. Track food intake OR track steps taken daily), setting goals (E.g. Eating 1 cup vegetable daily OR walk daily or 30 minutes), preventing
   relapse (E.g. Engage in strategies so that consumption of vegetables is easy OR Ask a friend to walk daily with you for accountability), controlling stimulus (E.g. Avoid keeping unhealthy food at home so that you don’t eat it OR If you have a friend to walk         with you are less likely to skip walking) and applying reinforcement (E.g. Reward self for small successes).
   o Social support is when family and friends model the behavior in front of the patient (E.g. Having co-workers, family members or friends practice similar behavior in front of the patient).

Conclusion
Poor diet quality has an enormous health impact including enhanced ASCVD risk. Improving behaviors such as diet quality and exercise among other CVD risk reduction behaviors can enhance quality of life and reduce healthcare costs. This provides strong rationale for the need to provide consistent diet and behavior assessments, education, and counseling for behavior modifications in those who will benefit from it. However, behavior change is a process and requires consistent support and time. Data on behavior counseling and improved cardiometabolic risk factors show that clinician-delivered behavior counseling has more impact and significantly improves cardiometabolic risk factors, supporting the adoption of routine integration of lifestyle assessment tools.

Disclosure statement:
Dr. Nazir has no financial disclosures to report. Dr. Poddar has no financial disclosures to report.

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