Life satisfaction and longitudinal changes in physical activity, diabetes and obesity among patients with cardiovascular diseases

In spite of a considerable decline during recent decades, cardiovascular diseases remain the leading cause of death in most OECD countries, accounting for nearly a third of all deaths in 2013 [1]. As a result of advances in treatment and intervention strategies, more people are surviving coronary heart disease-related events [2] and living with the associated burden of chronic disease, which could impact on satisfaction with life. Life satisfaction represents the perceived degree of discrepancy between individual aspirations and achievements, and contentment [3, 4]. Satisfaction with one’s own life has been the focus of many studies in the past decade both within and across countries, during a single time period and over time (i.e OCDE and Eurofound reports) [5–7]. In the same context, research using various medical diagnostic groups highlighted that life satisfaction in patients with chronic diseases varied widely between different subgroups, for example, life satisfaction in patients with cardiac infarction was higher than in those with diabetes type I. The satisfaction with life of patients was associated with angina, but not with myocardial infarction [8]. A global conclusion is that the objective severity of illness does not correlate very highly with LS [9]. The associations of co-morbidities such as diabetes, hypertension and obesity, and high levels of stress, caused by the disease itself, physical limitation and risk of death, represent a vicious circle that intensifies disease progression [10], which could represent an aggravating factor for the decline in life satisfaction. Elucidation of life satisfaction and its determinants in secondary prevention remains necessary; the follow--up of cohorts is particularly under-documented.

In reality, the prospect of a new decline in cardiovascular disease is likely to be compromised by the rise of cardiovascular risk factors such as obesity and diabetes [1], and the fact that they cause long-term disabilities [11], and affect life satisfaction [8, 12]. Secondary prevention has become an essential aspect of care of the patient with coronary heart disease [11]. A recent study in secondary prevention observed that the satisfaction with life of patients with cardiovascular risk factors (i.e obesity, diabetes, hypercholesterolemia and physical inactivity) was more likely to be lower [13]. A limited number of studies concerning follow-up of cohorts examine the evolution of the changes over time of cardiovascular risk factors. A beneficial or deleterious impact on satisfaction among patients who are in a period of life heavily influenced by work would show that life satisfaction and adaptation to various life events can differ by age and sex [14].

After a cardiac infarction, patients must reorganise their daily lives, adapt to preventive behaviour, adjust to their new lifestyles and available income, as well as rethink their plans for the future. It is well established that early management of cardiovascular risk factors through longitudinal lifestyle changes, secondary prevention and/or therapeutic intervention leads to a marked reduction in mortality and morbidity [15, 16]. Non-adherence to preventive measures is a powerful confounder of evidence-based practice and can affect daily patient management, resulting in inappropriate therapeutic escalation; it increases the risk of adverse cardiac events, including mortality [17]. It is recognized that patients with hypertension or hyperlipidaemia tend to take less than half of their prescribed medications [18]. Indeed, cardiac rehabilitation and secondary prevention programmes have developed from focusing on exercise alone to becoming multidisciplinary and encompassing baseline patient assessments, nutritional counselling, risk factor management (i.e., lipids, hypertension, weight, diabetes, and smoking), psychosocial and vocational counselling, and physical activity advice and exercise training, in addition to the appropriate use of cardioprotective drugs [11].

Adherence to medical advice, therapeutic programs and secondary preventive measures modifies risk factors, and thereby may impacts on LS. Longitudinal investigations may be of interest to identify psychosocial, cognitive and material factors that contribute to adherence to treatment/medication and/or the adoption of healthy behaviour, and which intervene on the gap between the intention or motivation of the patients to adjust their lifestyle and the feeling that they are able or unable to change their behaviour such as suggested by the empirical approach of Godin [19] and the conceptual approach of Sheeran [20]. Comprehension of these interactions has become an important criterion of research where greater knowledge may be useful in improving procedures used to follow up CVD patients. Indeed, a better understanding of the variability over time of the changes of CVRF in secondary prevention may help individuals and policy makers make better decisions that increase or maintain patients’ life satisfaction. In this context, the national of Luxembourg eHealth agency (National Agency for Shared Information in Health) has given patients the right to receive all available information about their health status and treatment options in order to help them make informed choices. This applies mostly to patients with chronic diseases such as cardiovascular diseases. This reform supports keeping personalized medicine high on the political agenda, in line with the European cross-border directive of 2011 [21]. Our aim in this study is to analyse the relationships between longitudinal changes between2008/9 and 2013/14, in cardiovascular risk factors (hypertension, hypercholesterolemia, diabetes, obesity, physical inactivity, and tobacco consumption) and socioeconomic factors on one hand, and their satisfaction with life in 2013/14 on the other hand.

Our research examined the associations between longitudinal changes in cardiovascular risk factors and satisfaction with life among cardiovascular disease patients, 5 years after coronary angiography. With regard to our major findings, first, a lower LS was observed when obesity or physical inactivity was already apparent or became so in 2013/14. Second, the same trend was not seen in patients with diabetes that was recorded in 2008/9, but only when it appeared in 2013/14. Third, the decrease in LS was lower when obesity and physical inactivity disappeared in 2013–2014. We will develop these findings point by point.

One of our most interesting findings was that the lowest LS was more likely when failure to exercise was declared in 2013/14. Although our results did not investigate gender differences, we propose to underline the conclusions of a study [25] which examined the change in physical activity-mediated gender-related satisfaction with life over a 2-year period. It showed that higher physical activity levels impact on satisfaction with life positively, but observed that males were engaged in more physical activity than were females. A systematic review of the impact of lifestyle interventions in the secondary prevention of coronary heart disease follow-up of 3 months [26] confirmed that the overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes. Hypotheses could be proposed to better understand the link between non adhesion to physical activity and satisfaction with life. Some of the patients probably had little motivation to adopt healthy behaviours or were not able to change [20], when they declared their inactivity 5 years after their event; they perceived their satisfaction with life negatively. In another study [27], data sets predicting behaviours in the health domain (smoking, applying universal precautions, exercising) were examined. Patients whose intentions were more aligned with the norms of the society were more likely to report healthy behaviours than were participants whose intentions differed [27]. Other suggestions that concerned reducing TV or computer time as well as targeting other healthy behaviours (eg. increasing physical activity levels, improving dietary intake) might prove useful [28]. In contrast, the more patients waste time by not becoming active, the more cardiovascular risk factors appear. In a Luxembourgish study [28], higher weekday sitting time was related to poorer cardiovascular health; time spent watching television was inversely associated with this score on both workdays and days off. Physical activity has been associated with improved physical fitness, social functioning, self-esteem, body image, mood, stress response; and a decreased risk of heart disease, and diabetes [29]. A longitudinal study of older people demonstrated that more time watching television was associated with incident central obesity after adjustment for covariables including physical activity, but not with total obesity when measured by BMI [30].

A second finding showed the same low trend on life satisfaction as previously when the risk of obesity was present in 2008/9 and in 2013/14, and when obesity appeared in 2013/14. In light of the previous hypothesis, and such proposals as those by Sheeran [20], we would suggest that during the 5 years after coronary angiography, these patients probably had most difficulty adapting their lifestyle and their life satisfaction had been perceived negatively because their intentions were questionable concerning medical advice and secondary prevention. Some authors [31] tried to account for the gap between knowledge of risk factors and change in unhealthy behaviour. Their conclusions indicated that intention is a moderate predictor of behaviour and that the gap between intention and behaviour is caused by high intenders not taking action. It is also necessary to recall that with long-term cardiovascular disabilities, social and familial repercussions on daily life, restrictions in routine, leisure and work activities, and socioeconomic impact, a proportion of patients go through a phase of depression and anxiety [32].

Another finding concerned longitudinal modifications in diabetes. The relationship with life satisfaction was deleterious, whereas lifestyle was more beneficial when obesity and physical inactivity disappeared in 2013/14. Patients who adjusted their lifestyles during the 5 years following a coronary angiography, are, we suppose, probably motivated, but are likely to have changed their behaviour against their will. They perceived adopting healthy behaviours as unpleasant, which may impact negatively on their life satisfaction. Effectively, patients who follow the strict regime prescribed and hence go from diabetes in 2008/9, to at least less severe diabetes in 2013/14, experienced a difficult period during which they maintained unpleasant lifestyle behaviours. In addition, eating carbohydrate-rich food is part of a ‘good life’ [1], but also a form of dependency. To abandon that and to limit ones diet and adopt physical activity could be devastating. Adherence to therapeutic advice and adjustment in lifestyle, including healthy eating and reducing the sugar intake in the diet, can reduce cardiovascular risk factors, and modify the satisfaction with life. For example, patients who must adopt a behaviour that is perceived as unpleasant, such as a diabetic regime, are affected emotionally because the gap between what they currently do and what they must do is likely to precipitate psychological difficulties. A better comprehension of the cognitive aspects of cardiovascular disease in relation to the affective aspects [33, 34] makes clear that what happens in the mind has to be taken into account if we want to understand how adapted lifestyles are adopted and how the ability to adhere to medication can be developed. Knowledge of the emotional impact of adherence may be useful for policy interventions aimed at improving the health and daily life of patients. Non-adherence is complex and remains difficult to define. In addition, the ability of providers to accurately identify at-risk patients is limited. Improved screening tools are needed to detect them and thereby facilitate appropriate targeting of interventions. Given the rapidly expanding global population with coronary heart disease and emerging clinical and cost-benefits of adherence, addressing non-adherence to prescribed therapies is a top priority [35].

Lastly, two other findings are worthy of a brief mention; the facts that being a woman and/or having a low income affect satisfaction with life. Firstly, in accord with this finding, in the presence of coronary artery disease, female-patients with co-morbidities such as diabetes, hypertension and obesity, presented greater impairment of their wellbeing. The unfavorable outcomes months after percutaneous coronary intervention were associated with female sex, a previous event, or procedure failure [36]. Another example, the rates of obesity and overweight vary according to educational level and socioeconomic status, and these disparities are significant among women, but less clear among men [37]. Secondly, the lower the income of study patients, the lower the life satisfaction. Lack of income would be greater already due to facing lifestyle disadvantages, and the consequences of CVD-related behaviours would be greater when they are confronted with new socioeconomic disadvantages like wages for domestic helpers. A study over time found that life satisfaction is lower when all the years of poverty are together rather than split up into periods in and out of poverty. This ties in with the idea that individuals may have the resources (financial or otherwise) to deal with relatively short-term poverty but not when it lasts too long [14].

Furthermore, our results showed that hypertension and hypercholesterolemia were not discriminant factors of the life satisfaction between patients with or without these risk factors. In other words, the link between the constraints related to treatments and to lifestyle changes of these risk factors, and the life satisfaction would be less strong than those associated to diabetes or obesity. Regarding the lack of a link between the evolution of tobacco consumption and LS, we can conclude that stopping smoking in a situation of medical stress can be experienced with difficulty.

Our research highlights the fact that information about the determinants of the satisfaction with life help explain certain difficulties encountered in secondary prevention. Maximising the comprehension of the potential of adherence, patients and professionals must discuss their respective roles as ‘Partners in Healthcare’ [45] and suggest that CVD-related upheavals can be minimised if they provide empowerment in diabetes, obesity and/or physical activity. Our findings call for further research into secondary prevention concerning the relation over time of socioeconomic conditions and the changes of cardiovascular risk factor related behaviours with patients’ life satisfaction. There may also be a need to evaluate the impact of psychosocial and material barriers or facilitators in the implementation of actions that would develop patients’ capability to adhere to medical advice and to adopt healthy lifestyles, as well as to reduce cardiovascular risk factors and enhance satisfaction with life.