Adherence to Prevention

28 May 2013

Adherence to Heart Attack and Stroke Prevention Recommendations is a joint physician, individual, and community responsibility

Dr. Hussain Isma’eel, MD, FESC, FSCCT
Co-Director, Vascular Medicine Program
Division of Cardiology
American University of Beirut, Lebanon
Yaduna - WHHC Cardiologist

We live today in a country where diagnosing coronary disease, hypertension, diabetes and other diseases has become much easier. Once a diagnosis is made, a plan of action is placed which includes several options ranging from lifestyle changes, to taking medications, and to more complex acts such as cardiac catheterization for example. When talking about prevention of heart attack, stroke, and death from heart attack, physicians are primarily referring to lifestyle changes and chronic medications intake. Adhering to the recommendations of physicians for these 2 requests is currently well-recognized to be a challenge for the healthcare system and therefore a barrier to better health outcomes for our patients.

To further elaborate about the issue of adherence, let’s start by explaining what we are asking our patients to do. In brief, in terms of therapeutic lifestyle changes, we are asking adults to change their diet to a healthier one (less salt, less sugar, and less saturated fats), exercise regularly, quit smoking, and lose weight if obese. In terms of medications, we need to spell out that most of the prescribed medications for hypertension, diabetes, dyslipidemia, or heart disease are medications for life- in the majority. Now that we have clarified what we are requesting, let’s dwell more on how much we are requesting in order to better understand how we can best do that.

In a recent study on ‘seemingly healthy Lebanese adults’, we found that > 80% of these individuals need lifestyle changes, around 10% were diabetic without knowing, around 12% were hypertensives without knowing, and around 24% were obese. As for requiring medications, such as lipid lowering medications in particular, around 19.4% needed these medications directly from the beginning. This is not forgetting that these are seemingly healthy individuals not known before to have any disease. Hence, can you imagine what the numbers will be if we include those who already have hypertension, coronary artery disease, diabetes or stroke?

The challenges of adhering to medications are numerous and some of these include: 1. Cost & accessibility, 2. false ideas about certain medications and diseases that patients do not communicate with the doctors, 3. doctors not informing their patients enough about their disease and the medications prescribed, 4. concerns about side effects (in particular when the side effect affects sexual performance or causes occupational embarrassment (such as needing to go the toilet frequently), and others), 5. Commitment issues: Young are reluctant to commit to life-long medications thinking ‘it’s too early’, and some elderly are passive about their health issues ‘how much longer will I live’ and 6. Memory issues (particularly when the number of medications increase).

To address the above, doctors and patients need to communicate freely so all issues are attended to. Cost and access to medications for many of the diseases is a matter that the ministry of health has worked on through providing generic medications from the Essential Drug List. Ask about this list and ask your doctors to prescribe from it. The majority of your drugs may be present at a very affordable price. As for the side effects of these medications, do not hesitate to communicate your concerns clearly and remember there are alternatives and solutions. And where commitment is an issue, do remember that prevention starts early and is much better than a heart attack, permanent disability or death. You are dear to your family, and it’s important you remain fit and healthy, and a contributor to the overall well-being of your family and community instead of becoming a tremendous burden.

In terms of adhering to lifestyle changes, this is where the issue is more demanding. It is important to remember that in most of the Lebanese houses, not all, mothers are still the main home administrators. That being a fact helps us focus our efforts through working with these women to ensure that they are our partners for a healthier society at large. It is much more effective to speak to the person, whoever that is, who purchases the groceries, or cooks, to get their buy-in to commit to making healthier eating choices. We need to cut down on our salt intake, sugar intake, and saturated fat intake. This can affect the spouse and the children, therefore increasing the benefit. Also, adults need to motivate each other, and the young, to perform regular exercise such as walking. Here, it’s important to know that walking adds-up i.e. something as simple as climbing the stairs instead of the elevators is of benefit! Working late hours is not an excuse for not walking to the grocery store instead of using the car! Last, the evidence in favor of quitting smoking is not questionable, and yes, Narghile has similar bad effects to smoking cigarettes. No matter which type of Narghile you smoke, nor how you smoke it, it is harmful. This should not be a family gathering activity, particularly that passive smoking, which is inhaling the fumes of what someone else has smoked just by being around in the room, is also dangerous to your health.

In conclusion, we need to remind everybody that prevention of heart attacks, strokes and sudden death starts early in life. It starts with leading a healthy lifestyle in terms of our diet, not smoking, and by exercising. It also means becoming aware of the need to control the diseases that increase heart attacks and strokes through adhering to prescribed medications. Patients need to develop a trust bond with their physicians, and both need to listen to each other to ensure the best outcome is achieved. Patients with chronic illnesses should not make changes in their medications on their own: Just Ask. Finally, each one of us needs to be a positive force driving the others for a healthier life.