Although lifestyle interventions show promise in combating cardiometabolic diseases, their long-term success depends on policy-driven environments that make healthy living accessible to all.
Study: Lifestyle Interventions for Cardiometabolic Health. Image credit: Shutterstock IA
A recent study published in the journal Natural medicine examined the benefits of combined lifestyle interventions (CLI) on cardiometabolic health.
Obesity and overweight are risk factors for cardiometabolic diseases (CMDs) and their global prevalence has tripled in recent decades. Societal changes have shifted from leisure activities or labor-intensive work to more sedentary and inactive lifestyles. At the same time, eating habits have shifted from plant-based diets to Western diets characterized by energy-dense, low-fiber, and high-sugar foods. The study highlights that these trends disproportionately affect socioeconomically disadvantaged populations, where the prevalence of CMD can be up to five times higher than in more affluent groups.
CLIs target several lifestyle behaviors and have the potential to prevent CMD in at-risk populations. However, in the long term, they are not always durable and their effects fade with routine care. In the present study, investigators examined the short- and long-term benefits and cost-effectiveness of CLI for obesity, overweight, and related CMDs in controlled studies and routine care.
Contributions of lifestyle behaviors to CMD risk
An unhealthy diet, high in saturated fats, sodium and added sugar, as well as low consumption of fruits and vegetables largely contribute to premature mortality linked to CMD. Collectively, they account for up to 35% of cardiovascular disease (CVD)-related deaths. Furthermore, physical inactivity impacts the development of CMD and contributes 6% and 7% to the burden of cardiovascular disease and type 2 diabetes (T2DM), respectively.
Additionally, sedentary behavior also increases the risk of CMD. Although other lifestyle behaviors, such as chronic stress and lack of sleep, are associated with higher risk of CMD, their contribution to the global burden of CMD is unclear. The study highlights that unhealthy behaviors often cluster together, particularly in disadvantaged communities, increasing the risk of premature death. Therefore, it is essential to address multiple lifestyle behaviors simultaneously to improve cardiometabolic health.
Effects of CLIs
CLIs are delivered by healthcare professionals in structured, controlled programs and typically target sedentary, exercise, and dietary behaviors. Evidence indicates that CLIs consistently reduced the incidence of T2D by approximately 40% over three to six years of intervention in high-risk individuals compared to usual care in controlled environments.
CLI effects are primarily due to a decrease in glycemic markers, body weight, blood pressure, and low-density lipoprotein cholesterol. Additionally, studies comparing CLIs to the blood sugar-lowering drug metformin observed that the drug was approximately half as effective as CLIs. A network meta-analysis found that a CLI reduced the risk of T2D by 60% compared with pharmacotherapy, and this effect was partly persistent for many years after the intervention. For example, the Finnish Diabetes Prevention Study reported a sustained 20% reduction in diabetes incidence 20 years after intervention, highlighting the potential for long-term benefits.
Longitudinal assessments of CLI beyond the active intervention period revealed a reduction in T2DM risk, albeit to a lesser extent, over 3 to 20 years of follow-up. Despite these long-term benefits, meta-analyses have not observed long-term benefits of CLI on cardiovascular disease or all-cause mortality. However, the Da Qing China Diabetes Prevention Study demonstrated a significant reduction in all-cause mortality and cardiovascular mortality after 23 years of follow-up, highlighting the variability of results across different settings.
CLI Implementation and Profitability
Studies have translated controlled CLI into routine care settings, given their promising effects on T2D risk. A meta-analysis of 25 translational or before-and-after studies found approximately one-third to one-half of the effectiveness seen in the original studies, with clinically relevant weight loss after one year leading to improvements in risk factors for DMC.
Based on these analyses, diabetes prevention programs have been implemented for people at high risk in Finland, the United States, Australia and the United Kingdom. However, evidence of the effectiveness of these implementations is limited, even if the programs appear to be effective for people who have completed them. Concerning the cost-effectiveness of CLI, there is little evidence in current practice. The study highlights the need for more in-depth economic evaluations, particularly in low- and middle-income countries where the prevalence of CMD is rapidly increasing.
Population-wide approaches for healthy lifestyles
Although CLIs have been shown to be effective in preventing metabolic diseases, targeting only high-risk individuals in routine care is not sufficient to reduce the prevalence of metabolic diseases in the population. Measures targeting the entire population are therefore necessary. Population-based approaches have successfully reduced smoking by 27-37%; this could be an example to inform policy decisions affecting other lifestyle behaviors.
Urban planning policies can also play a central role in reducing the risk of CMD. For example, designing walkable neighborhoods and increasing access to green spaces have been associated with lower rates of T2DM and cardiovascular disease. Likewise, implementing taxes on sugary drinks and subsidizing fruits and vegetables can positively influence dietary habits, particularly in underserved populations.
Concluding Remarks
Although CLIs provide CMD benefits in trials and clinically relevant improvements in translational studies, their long-term effects in routine practice require further evaluation. Furthermore, the driving factors and barriers to implementing CLI in routine practice need to be assessed. Together, CLIs can produce clinically relevant metabolic effects, particularly when enhanced by policy measures and supportive environments targeting lifestyle behaviors at the population level. As such, CLIs are expected to remain an essential part of approaches to combating the CMD epidemic.